X A1 ADDENDA COMPANION DOCUMENT PROFESSIONAL (004010X098A1)

Transcription

1 X A1 ADDENDA COMPANION DOCUMENT PROFESSIONAL (004010X098A1) Updated February 2006 Submission of the National Provider Identifier (NPI) IN ADDITION to the Empire assigned provider Number (EPIN) Submission of the American Express Authorization Number (Loop 2300, PWK01/02/05/06) Association, an association of independent Blue Cross and Blue Shield Plans.

2 INTRODUCTION The Federal Department of Health and Human Services has adopted regulations, under the Health Insurance Portability and Accountability Act (HIPAA), that establish minimum standards for certain electronic transactions conducted among health plans, clearinghouses and certain health care providers ( covered entities ). These rules were scheduled to go into effect October 16, However, most covered entities, including Empire BlueCross BlueShield, obtained a one-year extension. Empire BlueCross BlueShield will be compliant by October 16, Health care plans are required by law to have the ability to send and receive HIPAA compliant transactions. Effective October 16, 2003 only the X version 4010A1 identified under HIPAA will be supported for electronic claim submission. The HIPAA implementation guides provide assistance in developing and executing the electronic transfer of health care data. The implementation guides can be downloaded, free of charge, from the Washington Publishing Company website at The A1 (004010X098A1) implementation guide must be used for claim submission if you are currently submitting claims on the NSF electronic format. Based on the A1 (004010X098A1) implementation guide there are specific Empire business requirements that must be further clarified so entities can do business with Empire. This document will identify Empire specific requirements for the A1 (004010X098A1) implementation guide using available data within the implementation guide. Major Issues: Submission of R data elements (Monetary Amounts). Please review the general instruction section for the proper way to submit monetary amounts. If the monetary amounts are submitted incorrectly, your claims may suspend or process incorrectly. (Updated March 2004) Empire recommends sending no more than 5,000 claims per transmission. (Updated March 2004) Electronic Media Claims (EMC) bulletins will be issued documenting front-end edits, the use of the 997 Acknowledgement and the new EMC receipt report. Updated February 2006 Beginning February 10, 2006, Empire Blue Shield will begin to accept the National Provider Identifier (NPI) IN ADDITION to the Empire assigned provider number (EPIN), You must continue to submit the EPIN until further notice or your claims will reject. Additional information is provided within this document and EMC Bulletin BS. X A1 Professional (Implementation Guide X098A1) 1

3 Item Empire Requirement 1. Character Sets Supported by Empire Empire will support all values identified in the Basic and Extended Character Set documented in Appendix A of the A1 implementation guide. 2. Multiple ISA through IEA s in a file with different Receiver ID s (ISA08). The Extended Character Set includes lower case (a..z). Lower case alpha values are not allowed in fields with an ID attribute. They must be submitted in upper case as specified in the implementation guide. For example: BHT06 must equal CH and not ch. Empire will accept multiple ISA through IEA s in a file if the receiver type are for the same Receiver ID (ISA08). If your file contains multiple ISA through IEA s, the receiver ID in ISA08 must all be the same. All ISA through IEA s with a value in ISA08 equal to the ISA08 value in the first ISA segment in the file will process. All ISA through IEA s with a value in ISA08 not equal to the ISA08 value in the first ISA segment in the file will NOT be processed. 3. Mixed Transaction Sets Empire will only accept multiple transactions of the same type within a single transmission. For example, multiple 837 transactions. Empire will not support a single transmission containing different transactions such as an 837 (claim), 270 (eligibility request) and 276 (claim status request). Empire will not accept the 275 transaction until it becomes a HIPAA standard. Attachment data should be communicated through fax, mail or Combined Claim Submissions This document only addresses claims for processing by Empire Blue Cross Blue Shield. Submission of commercial claims will be addressed at a later date. 5. Subscriber ID Format Refer to the Detail Transaction Instruction Section of this document for submission format. The front-end documentation will contain complete edit requirements on the subscriber ID format. 6. Subscriber and Patient Last and First Name Must be alpha and may contain one embedded space/hyphen. Formats 7. Subscriber and Patient Name - middle initial Must equal A-Z or blank. format 8. Field Size Limitations External Code Sources - External code sources can limit the field size from what is defined in the implementation guide. If the implementation allows for 30 positions and the external code source defines 5 positions, the valid field size would be a maximum of five positions. Example: for HCPCS, the implementation guide allows for 30 positions. Since the HCPCS/CPT are five positions, the field size is reduced to five positions. Data Element 782 Refer to Appendix A in the X098A1 X A1 Professional (Implementation Guide X098A1) 2

4 Item Empire Requirement implementation guide. Data element 782 is limited to a maximum length of 10 characters including reported or implied places for cents. 9. X Acknowledgment Transaction An X Acknowledgment Transaction will be created for every claim functional group, GS through GE (GS01 equal to HC) submitted to Empire. The 997 reports accepted and rejected transactions (ST through SE) at the X12 standard level. Standard level errors are reported on rejected transactions. It is imperative that claim submitters retrieve and process the 997 transaction. Additional information on the 997 will be documented separately. 10. TA1 Interchange Acknowledgement As the 837 transaction is processed through our translator, a TA1 acknowledgment will be produced if there are any errors in the ISA and GS segments. The TA1 acknowledgement will not be sent to the submitter of the 837. The errors received will be reported on the Empire Receipt Report under the Transmission Summary section of the report. The error numbers match what would be reported in the TA105 element within the TA1 segment. Refer to section B.12, data element TA105 for a listing of the error numbers and narratives. 11. Submission of Electronic Adjustments The 837 allows for the electronic submission of adjustments to previously processed claims. Empire will apply certain business edits to insure we can facilitate the processing of adjustment transactions. We will accept valid 837 adjustments on all previously adjudicated claims regardless of the claim format used to submit the original claim. Fields required for submission of electronic adjustments include: 2300 CLM05-3 Must equal 7 or REF (REF01 equal to F8 ) 2300 REF (REF02 equal to Original Reference Number) 2300 NTE (NTE01 = ADD) Valid values for this element are defined in the Detail Transaction Instructions section of this document. Adjusted claims will go through the same level of editing as original claims. The claim adjustment must contain the data that is being changed from the original claim. The front-end edit documentation also contains specific edit requirements for submission of electronic adjustments. 12. Front End Validation The levels of editing performed in the front-end system will be documented separately. 13. Group Number Format Refer to the Detail Transaction Instruction section of this document for submission format. The front-end edit documentation will contain complete edit requirements on the group number. X A1 Professional (Implementation Guide X098A1) 3

5 Item Empire Requirement 14. Service Line Charge Amount Empire requires at least one service line with a dollar amount greater than zero. 15. Service Line Units This data element is defined as an R value and decimals are allowed per the HIPAA implementation guide. For service line units, Empire will only accept whole units. For example 1.0 would be allowed. If 1.5 is present, the claim will be returned with a business edit. 16. Type of Service Code in the National Standard Format (NSF) Format The Type of Service code is not supported in the X version 4010A1 transaction. Use service line modifiers when applicable to the service line. The modifiers are submitted in Loop 2400, SV1 segment. 17. Subscriber and Patient Loops Refer to the implementation guide for submission of claims when the subscriber and patient are the same and when the subscriber and patient are different. 18. Provider Number used for Blue Shield Claims Processing. NPI - Updated February 2006 You must continue to submit the Empire assigned provider number (EPIN) until further notice. The Billing Provider ID is required in Loop 2010AA. The Rendering Provider ID in Loop 2310B is only required if different than the Billing Provider in Loop 2010AA or the Pay-To Provider in Loop 2010AB. Empire will not use or validate the Pay to Provider in Loop 2010AB for claims processing. We recommend not using the Rendering Provider ID at the service level in Loop 2420A. Based on data supplied in the above loops, this is how Empire will process the claim: If 2010AA is present with a valid Blue Shield Provider Number and Loops 2310B or 2420A are not present, the Billing Provider ID in Loop 2010AA will be used for claims processing. If the Rendering Provider ID is present in 2310B and is different from the Billing Provider ID in Loop 2010AA, the Rendering Provider ID in Loop 2310B will be used for claims processing. As stated above, we recommend not using the Rendering Provider ID at the service level in Loop 2420A. However, If 2420A is present on each service line the following will occur: If the Rendering Provider ID s are the same on each service line, the Rendering Provider ID in Loop 2420A will be used for claims processing. The ID s in Loop 2010AA and 2310B will not be used for claims processing. If the Rendering Provider ID s are different on the service lines, the Rendering Provider ID in Loop 2310B will be used if different from what is in Loop 2010AA. If the Rendering Provider ID in Loop 2310B is not present or is equal to the Billing Provider ID in Loop 2010AA, then the Billing Provider ID in Loop 2010AA will be used for claims processing. X A1 Professional (Implementation Guide X098A1) 4

6 Item Empire Requirement NPI Update February 10, 2006 If the NPI is submitted in the NM109 with NM108 equal to XX, in Loops 2010AA, 2310B or 2420A, then the providers Federal Tax Identification Number or Social Security Number must be present in the REF segment of the same loop with REF01 equal to either EI or SY. The EI qualifier is required unless the provider does not have a Federal Tax Identification number. If the provider does not have a Federal Tax Identification Number, then the SY qualifier is required. The Federal Tax Id Number or Social Security Number will be edited against internal files for validity. If both the Federal Tax ID Number and Social Security Number are present, the Federal Tax ID number will be edited for validity. 19. Empire Provider Number Format NPI - Updated February 2006 You must continue to submit the Empire assigned provider number (EPIN) until further notice. The NPI will be validated in the future and additional documentation will be sent. The provider number has ten positions, as follows: Positions 1-2 Enter one of the following: Individual Provider Only: Enter two alphabetic characters identifying the initials of the Provider s first and last name. For example, JS John Smith. Group Provider Only: Enter the first two characters of the Group or Corporate Provider Name (Where the first letter of the Group or Corporate Name may be followed by a blank). For example, WE would be entered for West Medical Group. In the event a Provider has a long last name, for example a hyphenated last name, the first 2 alphas of the provider's last name are used. Position 3 Must contain a zero Position 4-8 Must contain the provider code Position 9 Must equal the provider s office where services were rendered (Address code 1, 2, 3). Position 10 Must contain a zero. If more than one provider treats the same patient, a separate claim must be submitted for each provider. 20. Delimiters Empire recommends using the delimiters defined in section A Character Name Delimiter * Asterisk Data Element Separator X A1 Professional (Implementation Guide X098A1) 5

7 Item Empire Requirement : Colon Sub-element Separator ~ Tilde Segment Terminator Use of other characters can be discussed during the testing period with trading partners. 21. Negative Values in R defined fields. Data element types defined in the implementation guide as R allow negative or positive values to be submitted. The front-end edit documentation will contain specific fields where negative values are not allowed. For these specific fields, if a leading minus (-) sign is present, the claim will be returned with an Empire business edit. 22. Empire Payer ID Format When Empire is identified as the payer, the format of the payer code must equal: The first two positions of the Payer ID must equal 00 followed by 803. Example: For non-empire subscribers, the first two positions of the Payer ID must equal 00 followed by the Plan Code on the subscriber s ID card. 23. Hierarchical Level Data Structure Please refer to section(s) , 2.3.2, and of the 837 Professional Implementation Guide for definition of the Hierarchical Level Data Structure and the use of the HL segments. Examples of the correct 837 HL structure are included. BHT01 of the 837 (004010X098A1) defines the hierarchical structure as Information Source, Subscriber, Dependent. The information source in this implementation guide is the Billing Provider. The implementation guide shows the subscribers nested under the specific provider and the dependents nested under the specific subscriber. Empire requires that all subscribers be sent under the previous provider HL and not sent under a different provider HL and using the parent ID number to associate the subscriber to the appropriate provider. Empire requires that all dependents be sent under the previous subscriber HL and not sent under a different subscriber HL and using the parent ID number to associate the dependent to the appropriate subscriber. There will be critical HL edits in place to fail the entire transaction if the subscriber and dependent hierarchical Parent ID Number (HL02) does not match to the previous provider or subscriber HL ID Number (HL01). See edits IG0103 and IG0104 below for a description. HL01 (Hierarchical ID Number) must begin with one and increment by one for each HL segment within a ST through SE. This number uniquely identifies the HL. It is also used to associate children to the specific HL s through out the ST through SE. HL02 is used to identify the Hierarchical Parent ID Number. The information source does not use this field since this is the highest level X A1 Professional (Implementation Guide X098A1) 6

8 Item Empire Requirement and the information source is the parent. The subscriber and dependent HL s are children to either the information source or the subscriber and use this element to identify the what parent HL they are subordinate to. HL critical implementation guide edits applied to the HL segments include the following: Hierarchy of Critical HL Edits: Performed 1 st : Processing stops if this IG edit is received. No additional IG editing performed. IG0002 Critical Error, HL01 Must Increment by 1 within the ST through SE Performed 2 nd : Processing stops if these two IG edits are received. No additional IG editing performed. IG0000 Critical Error, HL03 Missing/INV, Further Editing Not Performed IG0059 Critical Error, 1 st HL03 Not = 20 or 2 nd Not = 22 Performed 3 rd : Processing stops if this IG edit is received. No additional IG editing performed. IG0103 Subscriber HL parent ID must = the previous provider HL ID Performed 4 th : Processing stops if this IG edit is received. No additional IG editing performed. IG0104 Dependent HL parent ID must = the previous subscriber HL ID Performed 5 th : Processing stops if this IG edit is received. No additional IG editing performed. IG0106 Subscriber Hl Missing, Required when Loop 2300 is Present If any of the above edits are received, processing will stop. The errors must be corrected and the entire ST through SE must be resubmitted. Please refer to the validation documentation for additional information on these edits. If none of the above critical errors are received, all IG edits will be performed on all segments within the ST through SE X A1 Professional (Implementation Guide X098A1) 7

9 Item 24. R Decimal Data Elements (Monetary Amounts) Updated March 2004 Submission of R Decimal Data (Monetary Amounts) must be formatted properly or the claim may suspend or process incorrectly. Empire Requirement Please refer to section A in the 837 Implementation Guide for instructions on how to submit decimal data elements (Monetary Amounts). The implementation guide states: The decimal point always appears in the character stream if the decimal point is at any place other than the right end. If the value is an integer (decimal point at the right end) the decimal point should be omitted An example of an R data element is CLM02. There are many R data elements within the 837. Example: If you are submitting $300.00, populate the element as follows: CLM*123ABC*300* (Note: the 300 represents CLM02) If you populate the element with (CLM*123ABC*30000*), you are actually submitting 30, If you make this error, it will cause your claim to suspend or pay incorrectly. If the dollar amount you are submitting contains cents (300.12), you must include the decimal. CLM*123ABC*300.12* If you populate the element with (CLM*123ABC*30012*), you are actually submitting 30, If you make this error, it will cause your claim to suspend or pay incorrectly. 25. Transmission File Size Updated March Federal Tax Identification Number Requirement Updated April 2005 NPI - Updated February 10, 2006 Empire recommends sending no more than 5,000 claims per transmission. Effective for 837 claim submissions submitted on or after April 22, 2005, the Federal Tax Identification number that corresponds to the Empire Blue Shield billing provider and rendering provider numbers must be present and match to the Federal Tax identification number on the internal Empire provider file. See detail section for complete instructions. NPI Update February 10, 2006 If the NPI is submitted in the NM109 with NM108 equal to XX, within Loops 2010AA, 2310B or 2420A, then the providers Federal Tax Identification Number or Social Security Number must be present in the REF segment of the same loop with REF01 equal to either EI or SY. The EI qualifier is required unless the provider does not have a Federal Tax Identification number. If the provider does not have a Federal Tax Identification Number, then the SY qualifier is required. X A1 Professional (Implementation Guide X098A1) 8

10 Item Empire Requirement The Federal Tax Id Number or Social Security Number will be edited against internal files for validity. If the Federal Tax ID Number and Social Security Number are both present, The Federal Tax ID Number will be edited for validity. The NPI will be validated in the future and additional documentation will be sent. X A1 Professional (Implementation Guide X098A1) 9

11 This section of the document will follow the format of the implementation guide and list specific Empire requirements by segment and element. We are only documenting areas in the implementation guide where there are situational segments and elements or specific qualifiers within the elements that Empire requires to conduct business. In other cases, the implementation guide should be followed. Anywhere within our documentation where valid values are identified with a single quote, the quotes are not part of the valid value. 837P Loop 837P Segment Element Name and Element ISA05 Interchange ID Qualifier Must equal ZZ. ISA06 Interchange Sender ID Must equal the Empire assigned Submitter ID number. Your Submitter ID number is used as your Trading Partner ID for Empire s submitter validation against internal control files. ISA07 Interchange ID qualifier Must equal ZZ. ISA08 Interchange Receiver ID Must equal BS803. If your transmission contains multiple ISA through IEA s, the value in all ISA08 elements must be equal. ISA09 Interchange Date The Interchange Date must be present in ISA09 and must be in the YYMMDD format. The date must be equal to or less than the current date. Dates prior to the year 2000 and future dates are not allowed. ISA12 Interchange Control Version Must equal Number ISA14 Acknowledgement Requested Empire will not produce a TA1 Acknowledgment, however TA1 error messages will be reported on the EMC receipt report. ISA errors will be reported on the EMC receipt report. ISA15 Usage Indicator Valid values are P or T. A submitter must be authorized to submit claims to Empire. The submitter s claims must pass the test (T) phase before production (P) claim submission is allowed. Once approved for production claims, test files can be submitted at any time. GS02 Application Sender s Code Empire does not edit this element. The value submitted must meet the implementation guide attributes. GS03 Application Receiver s Code Must equal BS803 for Empire Blue Shield Claims. GS04 Date The Functional Group Creation Date must be present in GS04 and must be in CCYYMMDD format. The date must be equal to or less than the current date. Dates prior to the year 2000 and future dates are not allowed. GS05 Time The recommended format is HHMM. GS06 Group Control Number The X12 document, X12.6 Control Structure, section X A1 Professional (Implementation Guide X098A1) 10

12 837P Loop 837P Segment and Element Element Name states the GS06 and GE02 shall by themselves be unique within a reasonably extended time frame whose boundaries shall be defined by trading partner agreement. Empire requires the GS and GE control number to be unique within the ISA through IEA. The GS06 and GE02 control numbers must equal. GS08 Version/Release/Industry Must equal X098A1. Identifier Code BHT02 Transaction Set Purpose Code Must equal 00 or 18. Empire will accept both values. BHT06 Transaction Type Code Must equal CH. REF02 Transmission Type Code Must equal X098A1. This transaction is being used in a production mode. To indicate if a transmission is test or production, use ISA B NM109 Identification Code We recommend using the same value that was submitted in GS03. NPI - Updated February 2006: Loop 2010AA NM108 and NM109 are required elements. With the implementation of the National Provider Identifier, the provider Federal Tax ID Number, Social Security Number or the National Provider ID can be submitted in the NM108 and NM109. If the NPI is present in NM109 with NM108 equal to XX, then provider s Federal Tax Identification number or Social Security Number must be present in Loop 2010AA, REF02 with REF01 equal to EI or SY If the provider has a Federal Tax ID Number, the EI qualifier is required in REF01, with REF02 equal to the provider s Federal Tax Id Number. If the provider does not have a Federal Tax ID number, then the REF01 must contain a value of SY with REF02 equal to the providers Social Security Number. The Federal Tax Id Number or the Social Security Number will be edited for validity. The NPI will be edited for validity in the future. If there are multiple REF segments present and both the Federal Tax ID Number and Social Security Number are submitted, the Federal Tax Id Number will be used for validation. The EPIN must still continue to be submitted in the 2010AA REF segment until further notice. 2010AA NM108 Identification Code Qualifier Must equal 24, 34, or XX. 2010AA NM109 Updated April 2005 Billing Provider Primary Identification Number NPI - Updated February 2006 If the NPI is not present: Must equal the Federal Tax Identification number or the social security number that corresponds to the Empire Blue Shield provider number submitted in the REF segment with the 1B qualifier. This number will be validated against an internal file at Empire. If the provider has a Federal Tax ID Number the 24 qualifier must be present with the providers Federal Tax ID number. If the provider does not have a Federal Tax ID number, then the providers social security number must be present with the 34 qualifier. If the NPI is present in NM108 and NM109, then the X A1 Professional (Implementation Guide X098A1) 11

13 837P Loop 837P Segment and Element Element Name Federal Tax ID or Social Security Number must be present in the REF segment of this loop. A REF segment with REF01 equal to 1B is always required, this is the Empire assigned provider number. If the NPI is present in 2010AA NM1 segment (NM108 equal to XX and NM109 equal to provider NPI), then a second REF segment is required with either the EI or SY qualifier is required as applicable. 2010AA REF01 Reference Identification Qualifier NPI - Updated February 2006 Although this segment is situational in the implementation guide, Empire requires at least one REF segment with a 1B qualifier. There must be only one REF segment with a 1B qualifier. This qualifier identifies the Blue Shield provider number reported in REF02. This REF segment is required until further notice even if the NPI is present in the NM1 segment. If REF01 is equal to 1B, then 2010AA NM108 must equal 24 and NM109 must be present and equal to the Federal Tax Identification number if the provider has a Federal Tax Id Number or NM108 must equal 34 and NM109 must equal the provider s Social Security Number if the provider does not have a Federal Tax ID Number for the provider on the internal Empire provider file. This is the requirement when there is not an NPI present on the claim. When the NPI is present in 2010AA, NM108 equal to XX and NM109 equal to NPI, then a second REF segment is required with either REF01 equal to EI and REF02 equal to the provider s Federal Tax ID Number or REF01equal to SY and REF02 equal to providers Social Security Number. If the provider has a Federal Tax ID Number, it must be submitted. If multiple REF segments are present with the Federal Tax ID number and the Social Security Number, the Federal Tax ID Number will be edited for validity. 2010AA REF02 Billing Provider Secondary Identification Number As stated above, There must be a REF segment present with REF01 equal to 1B and REF02 equal to the Empire assigned provider number or your claims will reject. When REF01 is equal to 1B, REF02 must equal the 10 position Empire assigned Blue Shield provider number. This number is used for editing. The front-end edit documentation will contain complete requirements. When REF01 is equal to EI, REF02 must equal the providers Federal Tax Id Number (if applicable) When REF01 is equal SY and REF02 will equal the providers Social Security Number. X A1 Professional (Implementation Guide X098A1) 12

14 837P Loop 837P Segment and Element Element Name 2000B SBR01 Payer Responsibility Sequence Number Code 2000B SBR03 Insured Group or Policy Number If the NPI is present in the NM108 and NM109, then a REF segment with either the Federal Tax Id Number or Social Security Number is required. If the provider has a Federal Tax ID number, it must be submitted. If the value in Loop 2000B SBR01-1 equals T, there must be at least two repeats of Loop There must be one Loop 2320 SBR01 equal to P and one Loop 2320 SBR01 equal to S. If the value in Loop 2000B SBR01-1 equals S, there must be at least one occurrence of Loop 2320 with SBR01 equal to P. The implementation guide defines this element as a alpha numeric field with a minimum size of 1 and a maximum size of 30. Refer to section A in the implementation guide for submission of STRING data elements. AN attributes are string data elements. All Empire group numbers are numeric. A prefix (G, GC, YLG or any other prefix) should not be entered as part of the group number. If the subscriber ID prefix is equal to YLG, G, or GC: The group number must be present and left justified. Must not contain leading spaces. Positions 1-4 are significant values. Example: if your group number is 11, the SBR segment would look like this: SBR*P*18*11******BL~ An invalid segment would look like this: SBR*P*18*011******BL~ SBR*P*18*8011******BL~ Note: If the group number on the subscriber s ID card is 5 digits, beginning with the number 8, disregard and do not enter the number B SBR09 Claim Filing Indicator Code Must equal BL 2010BA NM102 Entity Type Indicator Must equal BA NM108 Identification Code Qualifier Must equal MI. X A1 Professional (Implementation Guide X098A1) 13

15 837P 837P Segment Element Name Loop and Element 2010BA NM109 Subscriber Primary Identifier Must equal the Empire assigned subscriber identification number as shown on Blue Shield ID Card. Do not enter the suffix or the dependent number. Refer to section A in the implementation guide for submission of STRING data elements. AN attributes are string data elements. The value entered: Must be left justified. Must not contain leading spaces Must not contain all alpha characters Must not contain embedded spaces or special characters Subscriber ID body must begin immediately following the alpha prefix. No space after prefix. The ID body must not contain all 1 s, 2 s, 3 s, 4 s, 5 s, 6 s, 7 s, 8 s, 9 s, 0 s, , or literals equal to UNKNOWN, UNK, INDIVIDUAL, SELF, NONE. Must not contain low values The front-end edit document will contain complete requirements for submission of the Subscriber Primary ID. 2010BB NM108 Identification Code Qualifier Must equal PI. 2010BB NM109 Payer Primary Identifier For Empire Blue Shield subscribers: NM109 must equal The first two positions must equal CA NM108 Identification Code Qualifier Must equal MI. 2010CA NM109 Patient Primary Identification Code For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. The same requirements apply to the Patient Primary Identifier that apply to the Subscriber Primary Identifier. Must equal the Empire assigned subscriber identification number as shown on Blue Shield ID Card. Do not enter the suffix or the dependent number. Refer to section A in the implementation guide for submission of STRING data elements. AN attributes X A1 Professional (Implementation Guide X098A1) 14

16 837P Loop 837P Segment and Element Element Name are string data elements. The value entered: Must be left justified. Must not contain leading spaces Must not contain all alpha characters Must not contain embedded spaces or special characters Patient ID body must begin immediately following the alpha prefix. No space after prefix. The ID body must not contain all 1 s, 2 s, 3 s, 4 s, 5 s, 6 s, 7 s, 8 s, 9 s, 0 s, , or literals equal to UNKNOWN, UNK, INDIVIDUAL, SELF, NONE. Must not contain low values 2300 CLM Claim Information Empire recommends sending no more than 5,000 claims per transmission. (Updated March 2004) CLM01 Patient Account Number Empire will only store up to 20 positions for a patient control number as noted in the implementation guide CLM02 SV102 Total Claim Charge Amount Line Item Charge Amount Total claim charge amount reported in CLM02 must equal the sum of all values reported in SV CLM05-3 Claim Frequency Code Must equal 1, 7, or CLM05-3 NTE02 NTE02 Claim Frequency Code Claim Note Line Note If value is equal to 7 or 8, then the first three positions in the 2300 or 2400 NTE02 must be populated with one of the following values to identify the reason for the claim adjustment: CHG, DOS, PVN, DIA, PRC, POS, UNT, MDF, OCA, IDC, DEP, SOA, MED, AUT, TFD, CDR, OTH. Definition of Values: CHG Charges (Total or Line) DOS Date of Service PVN Provider Number DIA Diagnosis Code PRC Procedure Code POS Place of Service UNT Number of Units MDF Modifier OCA Other carrier Allowance IDC ID Number Change DEP Dependent Number Change SOA Questioning Schedule of Allowance MED Medical Necessity Appeal AUT Authorization on File Appeal Denied TFD Timely Filing Denial Appeals CDR Contractual Denial Review X A1 Professional (Implementation Guide X098A1) 15

17 837P Loop 837P Segment and Element Element Name OTH Other 2300 CLM11-1,2,3, CLM11-4 CLM PWK01 Updated February PWK02 Updated February PWK05 Updated February PWK06 Updated February 2006 Related Causes Code Auto Accident State or Province Code Country Code Attachment Report Type Code Attachment Transmission Code Identification Code Qualifier Attachment Control Number The value of OTH should be used if none of the other values are appropriate. If CLM11-1,2,3 is equal to AA, then either CLM11-4 or 5 must be populated. To submit the American Express Authorization Number, the value in this element must equal CT. If entered, Empire supports values AA, BM, FX or EM. To submit the American Express Authorization Number, the value in this element must equal AA. To submit the American Express Authorization Number, the value in this element must equal AC. To submit the American Express Authorization Number, the value in this element must equal the American Express Authorization Number. This is a 6 digit alpha numeric value. Do no zero fill the element REF Original Reference Number (ICN/DCN) CR1 Ambulance Transport Information This is not the American Express Credit Card Number. Do not send the credit card number to Empire. A REF segment with a F8 qualifier is required when submitting electronic claim adjustments (CLM05-3 equal to 7 or 8 ). REF02 must be a minimum of 10 positions. The implementation guide requires this segment for claims involving ambulance services. Please refer to IG edit IG0107 for a list of the procedure codes that Empire considers as ambulance services CRC Ambulance Certification The implementation guide requires this segment for claims involving ambulance services. Please refer to IG edit IG0114 for a list of the procedure codes that Empire considers as ambulance services CRC Patient Condition Information: Vision The implementation guide requires this segment for claims involving replacement lenses or frames. Please refer to IG0066 for a list of the procedure codes that Empire considers as vision services HI Health Care Diagnosis Code Although the implementation guide defines this segment as situational, Empire does not process claims without a principal diagnosis code HI01 must equal BK HI02 must equal the Principal Diagnosis code. Other diagnosis codes can be supplied. 2310A NM1 Referring Provider Name NM101 equals DN or P3, Empire will accept either X A1 Professional (Implementation Guide X098A1) 16

18 837P Loop 2310B 837P Segment and Element NM1 Element Name Rendering Provider Name qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Referring Provider ID number is not validated. NM101 equals 82 (Rendering Physician ID) Updated April 2005 NPI - Updated February 2006 If the qualifier in REF01 is equal to 1B, Empire will require the qualifier of 24 in NM108 and the value submitted in NM109 must equal the Federal Tax Id Number if the provider has a Federal Tax ID Number or the qualifier of 34 and NM109 equal to the provider Social Security number if the provider does not have a Federal Tax ID Number for the provider number submitted with the 1B qualifier and must match the number on an Empire internal file UNLESS the provider submits the NPI in Loop 2310B (NM108 equal to XX and NM109 equal to the provider NPI). If REF01 is equal to 1B and the NPI is present the NM109 element, then another occurrence of the REF segment is required with REF01 equal to EI if the provider has a Federal Tax ID Number or SY if the provider does not have a Federal Tax ID Number. If the qualifier is equal to SY REF02 will equal the provider social security number. 2310B REF Updated April 2005 NPI - Updated February 2006 Rendering Provider Secondary Identification The Federal Tax ID number or the Social Security Number must match to the provider number submitted with the 1B qualifier and must match the number on an Empire internal file. If the provider has a Federal Tax ID Number, it must be submitted. If Loop 2310B is present with REF01 equal to 1B, REF02 must contain the 10 position Empire assigned Blue Shield provider number. If REF01 is equal to 1B, then 2310B NM108 must equal 24 and NM109 must be present and equal to the Federal Tax Identification number if the provider has a Federal Tax ID number or NM108 must equal 34 and NM109 must equal the Social Security number if the provider does not have a Federal Tax ID Number for the provider on the Empire internal provider file unless the NPI is present in NM108 (XX) and NM109 (NPI Number). If the NPI is present in the NM108 and NM109, then a second REF segment is required with REF01 equal to EI if the provider has a Federal Tax ID number or SY if the provider does not have a Federal Tax ID Number then the provider s Social Security Number will be present in REF02. X A1 Professional (Implementation Guide X098A1) 17

19 837P Loop 837P Segment and Element Element Name The Federal Tax Id Number and the Social Security Number will be edited for validity. If multiple REF segments are present with both the Federal Tax ID Number and the Social Security Number, the Federal Tax ID Number will be edited for validity. If the provider has a Federal Tax ID Number, it must be submitted. 2310D NM108 Service Facility Location NM101 equals QB (Purchased Service Physician ID) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Purchased Service Provider ID number is not validated 2310D NM1 Service Facility Location Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The number in NM109 is not validated 2310E NM1 Supervising Provider Name NM101 equals DQ (Supervising Physician) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Supervising Provider ID number is not validated 2320 SBR09 Claim Filing Indicator Code If value is equal to BL, then 2330B NM109 must equal the following: For Empire Blue Shield subscribers: NM109 must equal The first two positions must equal B NM109 Other Payer Primary Identification Number For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. If 2320 SBR09 is equal to BL For Empire Blue Shield subscribers: NM109 must equal The first two positions must equal 00 For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. Must equal HC SV101-1 Product or Service ID Qualifier 2400 SV101-2 Procedure Code SV101-1 uses external code source 130 (HCPCS) Codes. Empire will support non-standard HCPCS codes for claim dates of service prior to 10/16/2003. For claim dates of service after 10/16/2003, standard HCPCS codes must be used SV104 Units or Minutes The value must be greater than zero LIN03 National Drug Code Empire recommends that the National Drug Code be sent without any hyphens. X A1 Professional (Implementation Guide X098A1) 18

20 837P Loop 2420A 837P Segment and Element NM1 Updated April 2005 NPI - Updated February 2006 Element Name Rendering Provider Name NM101 equals 82 (Rendering Physician ID) Empire will require the qualifier of 24 or 34 in NM108 if the value in the 2420A REF01 is equal to 1B and the NPI is not being submitted. The value of 24 is required when the provider has a Federal Tax ID Number or 34 when the provider does not have a Federal Tax ID Number. The value submitted in NM109 must equal the Federal Tax Identification number when NM108 equal to 24 or the provider Social Security Number when NM108 is equal to 34 for the provider number submitted with the 1B qualifier and must match the number on the Empire internal provider file. 2420A REF Updated April 2005 NPI - Updated February 2006 Rendering Provider Secondary Identification If the NPI is submitted in NM108 and NM109, the provider Federal Tax ID Number or Social Security Number must be submitted in the REF segment with either qualifier EI or SY. If the provider has a Federal Tax ID Number, it must be submitted. If Loop 2420A is present with REF01 equal to 1B, REF02 must contain the 10 position Empire assigned Blue Shield provider number. If REF01 is equal to 1B, then 2420A NM108 must equal 24 or 34 and NM109 must be present and equal to the Federal Tax Identification number or the Social Security Number for the provider number associated with the 1B qualifier and must match to what is on the Empire internal provider file when the NPI is not submitted in NM108 and NM109. If the NPI is presenting NM108 and NM109, There must be a REF segment present with REF01 equal to EI and REF02 equal to the provider Federal Tax Id Number (if the provider has one) or REF01 must equal SY and REF02 must equal the provider Social Security Number if the provider does not have a Federal Tax ID Number. 2420B NM1 Purchased Service Provider Name If multiple REF segments are present with both EI and SY, the Federal Tax ID Number will be edited for validity. NM101 equals QB (Purchased Service Provider) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Purchased Service Provider ID number is not validated. 2420C NM108 Service Facility Location Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. X A1 Professional (Implementation Guide X098A1) 19

21 837P Loop 837P Segment and Element Element Name This number is not validated. 2420C NM108 Service Facility Location The Supervising Provider Id number is not validated. 2420E NM1 Ordering Provider Name NM101 equals DK (Ordering Physician) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Ordering Provider ID number is not validated. 2420F NM1 Referring Provider Name NM101 equals DN or P3 Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Referring Provider ID number is not validated. 2420G NM1 Other Payer Prior Authorization or Referral Number NM101 equals PR (Payer) NM108 must equal PI until the National Plan ID is implemented. X A1 Professional (Implementation Guide X098A1) 20