HIPAA ASC X12N Version 5010 Inbound 837 Transactions Companion Document Version 1.2 Release Date: April 1, 2014
Purpose This document has been prepared as a PerformCare companion document to the ASC X12N Implementation Guides, Version 5010, to clarify and assist providers in exchanging HIPAA compliant electronic data interchange (EDI) transactions. This companion document supplements, but does not contradict any requirements in the final ASC X12N Implementation Guides adopted by HIPAA. Rules for format, content, and field values can be found in the Implementation Guides. Covered entities are required to accept HIPAA Transactions in the standard format in which they are sent. Both PerformCare and its providers are HIPAA covered entities. The transactions currently supported by this Companion Document include the 837 Professional and 837 Institutional. Electronic Billing Methods PerformCare offers two methods for submission of HIPAA compliant transactions: Submitting through the Emdeon Clearinghouse or Direct Submit to PerformCare. Monthly claim volume will determine which method will apply to each provider. For those providers with claim volumes under 3000 claims per month, PerformCare has established a contract with Emdeon to facilitate the submission of electronic claims. For those providers with claim volumes over 3000 claims per month, we offer the choice of either direct submission or Emdeon. If you want to be considered for direct submission, contact PerformCare at edi@performcare.org to verify claim volume eligibility. If approved, you will be required to execute a trading partner agreement found in Appendix II. Submitting Electronic Claim Files through Emdeon Emdeon Payer ID for PerformCare is 65391. If your claim volume is less than 3000 claims per month, you will need to set up an agreement with Emdeon and submit the electronic files through them. They, in turn, will route all of the Health Choices provider claims directly to us. Notification on acceptance of the file will be through Emdeon. If you currently utilize a different clearinghouse for the submission of your claims, that clearinghouse will need to submit claims to Emdeon on your behalf. Additional questions should be directed to your assigned Account Executive. Emdeon is the electronic data interchange (EDI) services leader in healthcare and is already used by many of our providers. Emdeon provides EDI services based on individual needs, giving flexibility to providers for testing and submitting claims. Providers may contact Emdeon for provider solutions by calling 877-363-3666 or visiting their website http://www.emdeon.com/providers/. Property of PerformCare Page 2
Submitting Electronic Claims Directly to PerformCare If a provider meets the claim volume criteria for direct submission, PerformCare will require the receipt of a Point of Contact sheet and a Trading Partner Agreement prior to trading EDI files. PerformCare uses a secure web site to trade files. Please carefully read the instructions within this section in order to establish an EDI relationship with PerformCare. Your organization will need to generate HIPAA compliant EDI transactions. PerformCare technical support will be limited to transmission problems only, i.e. secure site, configuration, setup and connectivity. HIPAA compliance of EDI files is the responsibility of the submitting provider. Below is a flow chart for the 837 process. Point of Contact Sheet The Point of Contact Sheet (Appendix I) provides PerformCare information on two points of contact at your site, Legacy and Tax ID information, and transaction sets required. Providers are responsible for maintaining up to date contact information with PerformCare to insure that any changes or notifications are sent to the correct individuals. Trading Partner Agreement The Trading Partner Agreement (Appendix II) explains in detail the terms and conditions of exchanging data electronically. It must be signed by an executive level member of management authorized to enter into a legal agreement and accepted by PerformCare to activate the EDI Trading Partner relationship. Please note that for a Trading Partner submitting EDI files on its own behalf, a separate Trading Partner Agreement must be submitted for each tax identification (EIN/SSN) number. Property of PerformCare Page 3
Instructions for Initiating EDI with PerformCare To initiate the EDI process with PerformCare, please complete the following. Please note that Faxes are not permitted. 1. Complete the requested information in Appendix I and II Please do not staple these documents prior to mailing. Appendix I -- Point of Contact Document Appendix II -- Trading Partner Agreement Mail the above documents via the US Postal system to the address listed below: PerformCare ATTN: EDI-IT Department 8040 Carlson Road P. O. Box 6600 Harrisburg, PA 17112 Acceptance of Trading Partner Agreement Upon receipt of the Point of Contact sheet and the Trading Partner Agreement via the US Postal system, PerformCare will review the submitted documents. Upon acceptance of these documents, your organization will receive, via the US Postal system, confirmation of your user name and password, submitter ID information, as well as instructions on how to connect to the PerformCare secure website. The instructions on connecting to the secure website provide the necessary information to establish a successful connection. Since provider s internal systems are configured with various operating systems, desktop configurations, and network connections, PerformCare cannot provide technical assistance with setup. In addition to the connectivity instructions, your organization will receive additional identifiers that will be required on the HIPAA transaction to include a unique submitter ID. Changes to Point of Contact Document To change one or both contacts, please complete a new Point of Contact sheet and mail via U.S. Postal Service. PerformCare will review your request and confirm the changes using the email address on your point of contact sheet. It is the provider s responsibility to keep this information up to date. Deactivation of Trading Partner Agreement If a trading partner is inactive for one year, the Trading Partner agreement will automatically be deactivated as well as the logon ID and password. If your organization would like to continue the trading partner agreement, please submit your request to edi@performcare.org prior to the one year anniversary of the trading partner agreement. Property of PerformCare Page 4
General EDI Requirements The following are general EDI requirements for all files submitted to PerformCare: PerformCare will follow the recommended limit of 5000 Claims per transaction set as outlined in the HIPAA Implementation Guides. Only one GS/GE per file is permitted. Trading Partner File Protocol PerformCare maintains a secure website that is accessed with a username and password for the purpose of exchanging files. Each trading partner has one (or more) specific location(s) with exclusive access. PerformCare requires the following delimiters. Submitting delimiters other than those listed may result in a file rejection. CHARACTER NAME DELIMITER USE * Asterisk Data Element Separator : Colon Sub-element Separator ~ Tilde Segment Terminator NPI Requirements Registration Process All Health Choices Providers are required to register their NPI numbers as outlined in the DPW Medical Assistance Bulletin shown below. An NPI number used in an EDI transaction not registered with DPW will result in claim denial. Property of PerformCare Page 5
NPI Usage PerformCare is required under HIPAA guidelines to identify the provider by their NPI. PerformCare will use the NPI to derive the correct Medicaid (PROMISe ) number. Critical items used to derive the Medicaid number include the Billing NPI, Billing Zip Code, Treatment Zip Code (either Billing Zip or Service Facility Zip if different than Billing), taxonomy code(s), and rendering NPI and taxonomy if applicable. Every effort is made to derive the correct Medicaid number and service location code. An incorrect number may be derived if NPI + Taxonomy + Zip Code are not registered appropriately or incorrect/incomplete information is in the 837 file. Testing Process PerformCare requires all providers to successfully complete testing prior to being certified for electronic billing. Minimum testing requirements are outlined below. The goal of testing is to identify transaction structure and billing errors prior to production to insure a successful file acceptance rate once in production. The extent of testing required will be determined by the provider s ability to submit files according to HIPAA standards and PerformCare s billing requirements. Test File Requirements Minimum testing will require two files as identified below. If the provider bills for both institutional and professional services, the test file requirements below must be repeated for each transaction type. Test files must be placed in the TESTING INBOUND folder on the secure website. The flag for a test file must be set to a T in the EDI file (Interchange Control Segment - ISA15). An e-mail notification must be sent to edi@performcare.org when a test file is posted. The word Test must be somewhere in the subject of the e-mail. Following each submission PerformCare will send you notification of testing results that will be placed in the TESTING OUTBOUND folder. All test files must meet the WEDI-SNIP Test Type 1 and Type 2 HIPAA compliance. 1.1 Test File 1 Requirement The purpose of this test file is to test that the communications and identifying information are set up properly. This test file must contain a single claim that will be used to insure the provider submits a HIPAA compliant file along with the required identifiers to establish the provider s identity. File naming standards found within this document must also be followed for test files. 1.2 Test File 2 Requirement the purpose of this test file is to ensure the file does not contain HIPAA structural compliance errors. This test file must contain a normal production submission containing a variety of approved services the provider would normally bill to PerformCare. In particular, insure that services requiring authorization numbers, procedure code modifiers and different places of service are included in this submission. Provider will be required to submit additional Test #2 files at the discretion of PerformCare until the provider has successfully submitted a file that passes PerformCare billing requirements and would be accepted in production. Property of PerformCare Page 6
File Naming Requirements Test and Production file names must be unique and must follow the naming conventions below. Failure to follow these naming requirements will result in the file being ignored in the INBOUND folder Filenames cannot contain spaces. PHI, such as a member s name or ID number, cannot be used as part of a filename. A unique filename must be used at all times. Submitting the same filename more than once will result in the file not being processed and moved to the OUTBOUND folder with no further notification to the submitter. File Naming Conventions for All Submissions. Filenames must follow the established standard below. Filenames must be unique. PerformCare will not be responsible for the overwriting of duplicate file names in the INBOUND folder. id.ccyymmdd.uniqueselfdefined.h.837 Institutional/Hospital Claim Files id.ccyymmdd.uniqueselfdefined.m.837 Professional/Medical Claim Files id Submitter ID assigned with 5010 Trading Partner Agreement ccyymmdd = Date Format unique selfdefined = This is for your usage; it is self-defined and is required using the parameters described below: Any value that will make the file name unique Minimum of 1 character required Maximum of 17 characters allowed Must be alphanumeric; no special characters permitted h(m) h=hospital/institutional; m=medical/professional 837 = EDI file type EXAMPLES: 8999.20110824.inpatient0124.h.837 91.20110824.bhrs.m.837 101.20110824.01.m.837 Property of PerformCare Page 7
Production File Processing of Claim Files Providers will post production files in the INBOUND folder for automated processing. PerformCare is not responsible for the processing of files posted in any other location. File acknowledgement and Claim Acknowledgement reports will be posted in the OUTBOUND folder on the secure site once the file has been processed. Providers are responsible for accessing and downloading reports to their internal system. Files received for processing on the PerformCare secure website site must pass file naming conventions and HIPAA compliance before being uploaded to the claims system. File Name Validations File naming conventions must be adhered to due to automated job processes. Only files that meet the file name conventions and are unique will be processed. The submitter is responsible for monitoring the INBOUND directory for incorrectly named files. The submitter is also responsible for monitoring the OUTBOUND directory for any 837 files with a duplicate file name that may have been placed there. PerformCare is not responsible for the timely processing of files not conforming to established naming standards. File Level Acknowledgements PerformCare uses the Version 5010 HIPAA 999 File Acknowledgement Transaction to indicate file receipt and a status of Accept or Reject. PerformCare will use a full file accept or reject. A single HIPAA Type 1 or Type 2 error will result in full file rejection. File naming convention for File Level Acknowledgement is: <base file name>.999 (the.999 will replace the.837 from original file name). Incomplete files or files with serious structural defects may result in lack of receipt of a 999 File level acknowledgement. The submitter is responsible for monitoring and reconciling that a 999 is received for each 837 submitted. A submitter should expect to receive a 999 within two business days of submission. If a 999 is not received and the file is no longer in the Inbound folder, the submitter should assume PerformCare was unable to recognize the file and therefore unable to generate a response. Any questions on this issue should be directed to edi@performcare.org. Property of PerformCare Page 8
Claim Level Acknowledgements A Claim Level Acknowledgement Report will be saved to a text file and placed on the PerformCare secure website. The Claim Level Acknowledgement Report will include Patient Control Number, PerformCare claim number, Accept/Reject, Status, Reject Reason Code (if claim denied), Total Dollars, Total # Claims, and Original File Name. The Trading Partner is responsible for reviewing the report for acceptance/rejection of any claims. PerformCare is not responsible for any untimely billing denials for claims rejected due to electronic data interchange errors or failures. Status Codes on the Claim Level Acknowledgment include the following: 21 Carrier Acknowledges Receipt of Claim 86 Missing/Invalid Provider ID Prevents Carrier from Processing Claim BF Subscriber/Member ID Not Found A0 Payer Rejected Claim; No Further Updates to Follow File naming convention for Claim Level Acknowledgement is: <base file name>.ack (the.ack will replace the.837 from the original file name). FTP Site Usage Please note that the secure website is not a permanent storage location for any reports. PerformCare will routinely remove confirmation reports over 90 days based on the date of the filename. It is the trading partner s responsibility to move the received files to their internal systems for review and archiving. Disclaimer This Companion Document is intended to be a technical document describing the specific technical and procedural requirements for interfaces between PerformCare and its trading partners. It does not supersede either health plan contracts or the specific procedure manuals for various operational processes. If there is a conflict between this document and either the health plan contracts or operational procedure manuals, the contract or procedure manual will prevail. Substantial effort has been taken to minimize conflicts or errors; however, PerformCare and its employees will not be liable or responsible for any errors or expenses resulting from the use of information in this document. All material in this document is subject to change. If you believe there is an error in the document, please notify our Electronic Claims staff by sending an e-mail to edi@performcare.org immediately. Property of PerformCare Page 9
Appendix I Point of Contact Sheet Date: This Point of Contact Sheet is: Original Point of Contact Sheet Updated Point of Contact Sheet (used to convey any changes) PROVIDER S NAME TAX ID/SSN TAXONOMY CODES (LIST ALL THAT APPLY) PROMISe ASSIGNED MEDICAID NUMBER (9 Digit Number) If at any time changes are made to Electronic Billing, PerformCare will send notification to the two contacts listed below. It is the provider s responsibility to submit updates to PerformCare if the identified contacts change. CONTACT NAME ADDRESS PHONE # FAX # E-MAIL ADDRESS Transaction Types Please check the transactions you expect to submit and/or receive from PerformCare: 837 Health Care Claim: Institutional 837 Health Care Claim: Professional 835 Health Care Claim Payment/Advice Property of PerformCare Page 10
Appendix II Trading Partner Agreement The Trading Partner Agreement ( Agreement ) is made on this day of, 20 (the Effective Date ), by and between ( Trading Partner ), whose Federal Employer Identification Number (FEIN) is, and with Community Behavioral Healthcare Network of Pennsylvania, Capital Area (PerformCare). The Trading Partner intends to conduct PerformCare transactions in electronic form. Both parties acknowledge and agree that the privacy and security of data held by or exchanged between them is of utmost priority. Each party agrees to take all steps reasonably necessary to ensure that all electronic transactions between them conform to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and regulations promulgated thereunder. The parties agree as follows: 1. General Obligations. 1.1 Communications. The Companion Guide sets forth specifications for establishing connectivity with and transmitting transactions with PerformCare. PerformCare will provide file acknowledgements for documents submitted. Trading Partner agrees to retrieve and review documents as outlined in the Companion Document. PerformCare has the right to amend the Companion Guide and/or provide additional specifications to Trading Partner from time to time. Trading Partner shall be required to implement such amendments and additions within thirty (30) calendar days following PerformCare publication of same, unless a shorter period is necessary to conform to applicable laws and/or regulations. 1.2 Testing Requirements. The Companion Guide sets forth the testing requirements that Trading Partner and/or its contractors and/or agents must implement and/or complete prior to submitting live, production transactions to PerformCare. Trading Partner agrees to satisfy these requirements. 1.3 Security Requirements. (a) Each party will take reasonable care to ensure that the information submitted in each transaction is timely, complete, accurate and secure, and will take reasonable precautions to prevent unauthorized access to: its own and the other party s transmission and processing systems; the transmissions themselves; and the control structure applied to transmissions between them. (b) Each party is solely responsible for the preservation, privacy and security of data in its possession, including data in transmission received from the other party and other persons. If either party receives from the other data not intended for it, the receiving party will immediately notify the sender to arrange for its return, re-transmission, or destruction, as the other party directs. (c) The parties cannot change the data elements or standards for the transactions. Property of PerformCare Page 11
1.4 Costs and Expenses. Each party shall be responsible for any and all costs and expenses related to such party s compliance with the Transaction Regulations, any applicable Implementation Specifications and the terms of this Agreement. Further, each party shall be responsible for all costs, charges and fees it may incur in connection with transmitting and receiving Transactions. 2. Termination. 2.1 Effect of Termination. This agreement shall remain in effect until one party provides written notice of termination to the other, and thirty (30) days have elapsed following the other party s receipt of the notice. Termination or expiration of this Agreement or any other contract between the parties does not relieve either party of its obligations under this Agreement and under federal and state laws and regulations pertaining to the privacy and security of Individually Identifiable Health Information nor its obligations regarding the confidentiality of proprietary information. 2.2 Limit of Liability. Neither party shall be liable to the other for any direct consequential, incidental, indirect, exemplary, special or punitive damages, regardless of whether the claim giving rise to such damages is based upon breach of warranty, breach of contract, negligence, tort, or other theory of liability, even if a party has been advised of the possibility thereof. IN WITNESS WHEREOF, PerformCare and Trading Partner have caused this Agreement to be signed and delivered by their duly authorized representatives as of the date set forth above. ON BEHALF OF PerformCare By: Printed Name: Title: TRADING PARTNER By: Printed Name: Title: Property of PerformCare Page 12