SCAN HEALTH PLAN Standard Companion Guide Transaction Instructions related to the 837 Health Care Claim: Institutional Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2 837P Companion Guide Version Number: 2.0 April 11, 2013 Page 1 of 15
Preface This Companion Guide contains information to assist SCAN s Trading Partners in the submission of encounter data. The SCAN Companion Guide is under development and the information in this version reflects current decisions and will be modified on a regular basis. All versions of the SCAN Companion Guide are identified by a version number which is located in the version control log on the last page of the document. Users should verify they are using the most current. Questions regarding the contents of the SCAN Companion Guide should be directed to cmsfed@scanhealthplan.com Table of Contents 1 Introduction...3 1.1 Scope... 3 1.2 Overview... 3 1.3 Definition of key Terms... 3 1.4 References... 3 2 Contact...4 3 Control Segments/envelopes...4 3.1 ISA-IEA... 4 3.2 GS-GE... 5 3.3 ST-SE... 6 3.4 BHT... 7 4 837 Institutional: Data Element Table...7 5 Appendices...15 5.1 Business Rules... 15 5.2 Version Control Log... 15 Page 2 of 15
1 Introduction 1.1 Scope The SCAN Companion Guide for the 837-I transactions addresses how Trading Partners should send encounter data to SCAN. This Companion Guide must be used in conjunction with the associated 837-I Implementation Guide (TR3). The instructions in this Companion Guide are not intended to be a stand-alone requirements document. 1.2 Overview This Companion Guide includes information needed for Trading Partners to create Institutional encounter data files for transmission to SCAN Health Plan. The information is organized in the sections listed below: Contacts and Resources: This section includes telephone numbers and email addresses for SCAN as well as applicable website resources. Encounter Data: This section includes fields required by SCAN for Encounter Data processing in grids with required Loop/Segment/data elements/value/note/constraint. Version control Log: This section contains the revision history of the document. 1.3 Definition of key Terms Term SCAN CMS Definition SCAN Health Plan (MAO) Centers for Medicare and Medicaid Services 1.4 References Trading Partners can access our regularly updated FAQ list, our webinars and other documentation online under the Provider Tools section of the SCAN website. SCAN Provider Tools Website: http://www.scanhealthplan.com/article/physicianshospitals/fullencounterdata/fullencounterdata.html Page 3 of 15
2 Contact 2.1 SCAN Contracts Title Contact Phone Contact Email Char Beecher Manager, EDI 562-308-1126 cbeecher@scanhealthplan.com Marc Carren Director, Informatics and Data Interchange 562-997-1821 mcarren@scanhealthplan.com Viraj Desilva Sr. Encounter Data Specialist - Technical 562-989-4450 VDesilva@scanhealthplan.com Irina Masharova EDI Developer 562-308-4335 IMasharova@scanhealthplan.com 2.2 Resources Resource ANSI ASC X12 TR3 Implementation Guides Washington Publishing Company Health Care Code Sets SCAN Provider Tools Website Website http://www.wpc-edi.com/ http://www.wpc-edi.com/ http://www.scanhealthplan.com/article/physicianshospitals/ fullencounterdata/fullencounterdata.html 3 Control Segments/envelopes 3.1 ISA-IEA There are several elements within the ISA-IEA interchange that must be populated specifically for SCAN. Table 2 below provides SCAN (ISA-IEA) data elements. Table 2 ISA-IEA INTERCHANGE ELEMENTS Loop Segment Data Element Comments/Value Header ISA ISA01: Authorization Segment or Loop Requirement 00 Note "00" = No Authorization Present Page 4 of 15
Header Header ISA ISA ISA02: Authorization ISA03: Security 00 Header ISA ISA04:Security Use 10 blank spaces "00" = No Security Present Use 10 blank spaces Header ISA ISA05: Interchange ID Header ISA ISA06: Interchange Sender ID ZZ "ZZ" = Mutually Defined Use the Submitter ID assigned by SCAN Health Plan Please contact SCAN to obtain your Submitter Id. Header ISA ISA07:Interchange ID ZZ "ZZ" = Mutually Defined Header ISA ISA08: Interchange Receiver ID Header ISA ISA09: Interchange Date Header Header ISA ISA ISA13: Interchange Control Number ISA14: Acknowledgement Requested Header ISA ISA15: Usage Indicator Trailer IEA IEA02: Interchange Control Number "SCANCA3800" Transmission Date (YYMMDD) Control Number from System 0 1 "P" T Must be a fixed length with nine (9) characters and match IEA02 "0" = No Acknowledgement Requested 1 = Interchange Acknowledgment Requested (TA1 or 999) "T" = Test (Please coordinate with SCAN if you are sending Test data) "P" = Production (value must be "P" for production data) Must match the value in ISA13. 3.2 GS-GE There are several elements within the GS-GE that must be populated specifically for SCAN. Table 3 provides SCAN required (GS-GE) data elements. Page 5 of 15
TABLE 3 - GS-GE FUNCTIONAL GROUP ELEMENTS Loop Segment Data Element Comments Segment or Loop Requirement Note Header GS GS01: Functional Identifier Code Header GS GS02: Application Sender's Code Header GS GS03: Application Receiver's Code Header GS GS06: Group Control Number Header GS GS08: Version/Release Industry ID Code Trailer GE GE02: Group Control Number "HC" Use the Submitter ID assigned by SCAN Health Plan Please contact SCAN to obtain your Submitter Id. "SCANCA3800" This value must match the value in ISA08 005010X223A2 This value must match the value in GE02 This Value must match the value in GS06 3.3 ST-SE There are several elements that must be populated specifically for encounter data purposes. Table 4 provides transaction set (ST-SE) specific elements. TABLE 4 - ST-SE TRANSACTION SET HEADER AND TRAILER ELEMENTS Loop Segment Data Element Comments Segment or Loop Requirement Note Header ST ST01: Transaction Set ID Code Header ST ST02: Transaction Set Control Number Header ST ST03: Implementation Convention Reference Trailer SE SE01: Number of Included Segments "837" 005010X223A2 This value must match the value in SE02 Total number of segments included in a transaction set including ST and SE segments Page 6 of 15
Loop Segment Data Element Comments Segment or Loop Requirement Note Trailer SE SE02: Transaction Set Control Number This value must match the value in ST02 3.4 BHT There are several elements that must be populated specifically for encounter data purposes. Table 5 provides BHT specific elements. Table 5 BHT - BEGINNING OF HIERARCHICAL TRANSACTION Loop Segment Data Element Comments Segment or Loop Requirement Note Header BHT BHT01: Hierarchical Structure Code Header BHT BHT03: Reference Identification Header BHT BHT06: Transaction Type Code "0019" RP CH Batch Control Number "RP" = Encounters CH = Chargeable 4 837 Institutional: Data Element Table Within the ST-SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information. The 837 Institutional Data Element table provides users with Loops, Segments, Data Elements, values and notes as specific to SCAN. Not all data elements listed in the table are required; however, if they are used, the table reflects the values SCAN expects to see. Trading Partners should refer to 837I 5010 TR3 implementation guide for the complete transaction set and requirements. TABLE 6-837 INSTITUTIONAL HEALTH CARE CLAIM Submitter Submitter 02: Entity Type 09:Submitter Identifier 2 "2" (Non Person) Use the Submitter ID assigned by SCAN Health Plan Please contact SCAN to obtain your Submitter Id. Page 7 of 15
Submitter Submitter Submitter Submitter Submitter Submitter 1000B: Receiver 1000B: Receiver 1000B: Receiver 2010AA: Billing Provider 2010AA: Billing Provider 2010AA: Billing Provider City/State/Zip PER PER PER PER PER PER PER03: Communication Number PER04: COMMUNICATION NUMBER PER05: Communication Number PER06: Communication Number PER07: Communication Number PER07: Communication Number 02: Entity Type 03: Receiver 09: Receiver ID 08: Billing Provider ID 09: Billing Provider Identifier "TE" "EM" "FX" Situational Situational Situational Situational Email address of contact person Fax number "2" "2" = Non Person "SCAN Health Plan" "SCANCA3800" "XX" NPI Identifier Billing Provider NPI If Billing Provider is Exempt, use CMS default NPI 1999999976 N4 N403: Zip Code 999999998 The full nine (9) digits of the ZIP Code are required. If the last four (4) digits of the ZIP code are not available, populate a default value of 9998 Page 8 of 15
2010AA: BILLING PROVIDER TAX INDENTIFICATION REF REF01: Billing Provider TAX ID EI EI=Tax Identification Number 2000B: Subscriber SBR SBR01: Payer responsibility Number code "S" Code identifying the insurance carrier's level of responsibility for a payment of a claim "P" = Primary "S" = Secondary "T" = Tertiary 2000B: Subscriber SBR SBR09: Claim Filing Indicator Code "16" Must be populated with a value of 16 Health Maintenance Organization Medicare Risk. Must be identical to the value populated in Loop 2320, SBR09 2010BA: Subscriber 2010BA: Subscriber 2010BB: Payer 2010BB: Payer 2010BB: Payer 2010BB: Payer Address 2010BB: Payer City/State/Zip 2010BB: Payer City/State/Zip N3 08: Subscriber Id 09: Subscriber Primary Identifier 03: Payer 08: Payer ID 09: Payer Identification N301: Payer Address Line "MI" Member ID SCAN Member ID SCAN Member ID is 11 digits long and begins with 310 or 311 "SCAN Health Plan" "XV" PI "SCANCA3800" "3800 Kilroy Airport Way" N4 N401: Payer City "Long Beach" N4 N402: Payer State "CA" SCAN Address line Page 9 of 15
2010BB: Payer City/State/Zip N4 N403: Payer ZIP Code "90806" 2300: Claim 2300: Claim 2300: Claim CLM CLM DTP CLM02: Total Claim Charge Amount CLM05-3: Claim Frequency Type Code DTP03: Discharge Time 1 =Original claim submission 2 =Interim First Claim 3 =Interim Continuing Claim 4 =Interim Last Claim 7 =Replacement 8 =Deletion 9 Final Claim for a Home Health PPS Episode Must balance to the sum SV2 service lines in Loop 2400 Situational Hours (HH) are expressed as 00 for midnight, 01 for 1A.M., and so on through 23 for 11P.M. 2300: Claim CLM CLM08: Benefits Assignment Certification Indicator "Y" = Yes "N" = No required Minutes (MM) are expressed as 00 through 59. If the actual minutes are not known, use a default of 00 Page 10 of 15
2300: Claim PWK PWK01: Report Type Code "09" Situational 09: Populated for chart review submission only Indicates chart review additions and deletions 2300: Claim PWK PWK02: Attachment Transmission Code "AA" Situational Populated for chart review 2300: Claim CN1 CN101: Contract Type Code 05 Situational Populated for capitated arrangements. Applies to the entire claim. 2300: Claim 2300: Claim REF REF REF01: Original Reference Number REF02: Payer Claim Control Number F8" Situational Populated for Linked Chart Review, while CLM05-3 remains 1 for original encounter. Chart review data can also be sent as a correct/replace review in which CLM05-3 would be 7. Situational Identifies ICN from original claim when submitting adjustment or chart review data. 2300: Claim 2300: Claim - Medical Record Number REF REF REF01: Medical Record Identification REF02: Medical Record Identification EA Situational Populated for Chart Review Data. REF02, will either be 8 or will contain the diagnosis codes to delete from the original encounter. 8 Situational Chart review delete diagnosis code submissions only Identifies the diagnosis code populated in Loop 2300, HI must be deleted from the encounter ICN in Loop 2300, REF02 Page 11 of 15
Deleted Diagnosis Code(s) Diagnosis code(s) that must be deleted from the encounter ICN in Loop 2300, REF02 for chart review add and delete specific diagnosis codes on a single encounter submissions only. 2300: Claim Note NTE NTE01 ADD Situational Used only for submitting Proxy Data for a limited set of circumstances. 2300: Claim Note NTE NTE02: Proxy Data Reason Code 2300: Claim 036 040 044 048 052 056 Situational 036: Rejected Line Extraction 040: Medicaid Service Line Extraction 044: EDS Acceptable Anesthesia Modifier 048: Default NPI for atypical provider 052: Default EIN for atypical providers 056: Chart Review Default Procedure Codes HI HI01-2 Value Code A0 on all ambulance encounters 2300: Claim 2320: Other Subscriber HI HI01-5 Value Code Amount SBR SBR01: Payer Responsibility Sequence Number Code Must include the ambulance pick-up location ZIP Code+4, when available, in the following format: xxxxxxxx.x "P" Code identifying the insurance carrier's level of responsibility for a payment of a claim. For Post Adjudicated Claims Page 12 of 15
(COB), Loop 2320 must be Primary. 2320: Other Subscriber SBR SBR09: Claim Filing Indicator "P" = Primary "S" = Secondary "T" = Tertiary "16" Must be identical to the value in Loop 2000B, SBR09 2320: Claims Level Adjustment CAS CAS02: Adjustment Reason Code Situational when service line is denied in the MAO or other entities adjudication system 2320: COB Payer Paid Amount AMT AMT02: Payer Paid Amount amount CMS requires Post Adjudicated claims as encounters. Populate with the actual amount adjusted or 0.00 if there is no adjustment 2320: Coverage OI OI03: Benefits Assignment Certification Indicator "Y" = Yes "N" = No Must match the value in Loop 2300, CLM08 2330A: Other Subscriber 08: Identification Code "MI" 2330A: Other Subscriber 09: Subscriber Primary Identifier Page 13 of 15
2330B: Other Payer 08: Identification Code "XV" PI 2330B: Other Payer 09: Other Payer Primary Identifier 2330B: Other Payer Claim Adjustment Indicator 2330B: Other Payer Claim Adjustment Indicator 2430: Line Adjudication System REF REF SVD REF01: Reference Identification REF02: Other Payer Claim Adjustment Indicator SVD02: Service Line Paid Amount "T4" Must be populated because the claim is being sent in the payerto-payer COB model, and the destination payer is secondary to the payer identified in this loop. The payer may be in both instances the same, SCAN "Y" Must be populated because the claim is being sent in the payerto-payer COB model, and the destination payer is secondary to the payer identified in this loop. Amount The SVD segment is required by CMS for post adjudicated encounters. Zero (0) is acceptable for this element 2430: Line Adjudication System CAS CAS02: Adjustment Reason Code Situtational when service line is denied in the MAO or other entities adjudication system Page 14 of 15
5 Appendices 5.1 Business Rules 5.1.1 Encounter File size must be limited to 5000 CLM segments per file. 5.1.2 Trading Partners must submit encounters to SCAN no less than twice per week. 5.1.3 SCAN allows duplicate encounter data to be submitted when only the diagnosis codes are different. Often times, a provider partner\medical group has a need to send more diagnosis codes than the v5010 837I data set allows. 5.1.4 File Naming Convention: <Clearinghouse Batchid>_<Clearinghouse >_ENCOUNTERS_<formatype (837I or 837P)>_<Date in YYYYMMDD>_iterator (where applicable) Example: 12345_ABCFileProcessors_ ENCOUNTERS _837I_20130417 12345_ABCFileProcessors _ ENCOUNTERS _837I_20130417_1 (iterators of 1,2,3,etc. used when batches are split, or batch resent, etc.) 5.2 Version Control Log Version Version or Change Explanation By Date 1.0 Initial Draft Santosh Barakoti 08/30/2011 2.0 Updates Char Beecher 04/12/2013 Page 15 of 15