X A1 ADDENDA COMPANION DOCUMENT INSTITUTIONAL (004010X096A1)

Transcription

1 X A1 ADDENDA COMPANION DOCUMENT INSTITUTIONAL (004010X096A1) 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)

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 transactions. 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 (004010X096A1) implementation guide should be used for claim submission if you are currently submitting claims on the UB-92 electronic format. Based on the A1 (004010X096A1) 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 (004010X096A1) implementation guide using available data within the implementation guide. Major Items: HIPAA requires a HCPCS code on every outpatient service line. Empire will only require HCPCS codes when a contract has been negotiated. HCPCS codes will be accepted if sent on every outpatient service line. We will not require a corresponding HCPCS code on outpatient claim lines if the revenue code (e.g., 270) has no corresponding HCPCS equivalent. Submission of R data elements (Monetary Amounts). Please review the general instructions 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 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. Update February 2006 Beginning February 10, 2006, Empire Blue Cross 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 BC. X INSTITUTIONAL (Implementation Guide X096A1) 1 Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue

3 GENERAL INSTRUCTIONS Electronic Media Claims (EMC) bulletins will be issued documenting the front-end edits, the use of the 997 Acknowledgement and the new EMC receipt report. Report Printing: A new front-end receipt report has been developed for 837 version 4010A1 transactions. The report will provide a status of each ISA through IEA. The new report number is EMCD R01 for production transmissions and EMCD6110-R11for new biller transmissions. The report must be printed landscape. Item 1. There are many notes in the implementation guide that require data based on an inpatient or outpatient claim. The implementation guide does not define inpatient and outpatient. Empire determines the claim type based on the type of bill. Empire Requirement Empire definition of Institutional Claim Types: Inpatient Type of Bills: 11X, 12X, 17X, 18X, 21X, 22X, 27X,28X, 81X, and 82X Note: 81X and 82X will only be referenced as inpatient when revenue code 655, 656 or 658 is present. Outpatient Type of Bills: 13X,14X, 23X, 33X, 34X, 71X, 72X, 73X, 74X, 75X, 76X and 83X Home Health Type of Bills: 33X and 34X Hospice Type of Bills: 81X, and 82X Note: 81X and 82X will only be referenced as hospice when there is no presence of revenue code 655, 656 or 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. 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. 1

4 GENERAL INSTRUCTIONS Item 3. Multiple ISA through IEA s in a file with different Receiver ID s (ISA08). Empire Requirement Empire will accept multiple ISA through IEA s in a file if the receiver types 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. 4. Mixed Transaction Sets Empire will only accept multiple transactions of the same type within a single transmission (ISA through IEA). 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 . Alcohol-Substance Abuse attachment data can be submitted electronically in the UB-92 specification. The A1 does not support this function. 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. 6. Subscriber ID 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 subscriber ID. 7. Subscriber and Patient Last and First Name Formats Must be Alpha and may contain one embedded space and/or hyphen. 8. Subscriber and patient name middle initial format Must equal A-Z or blank. 9. Field Size Limitations External Code Sources External code sources can limit the field size from what is defined in the implementation guide. If the IG allows for 30 positions and the external code source defines 2 positions, the valid field size would be a maximum of two positions. Example: For Condition Codes, the IG allows for 30 positions. Since the Condition codes are defined by NUBC as 2 positions, the field size is reduced to 2 positions. Data Element 782 Refer to Appendix A in the X096A1 implementation guide. Data element 782 is 2

5 GENERAL INSTRUCTIONS Item Empire Requirement limited to a maximum length of 10 characters including reported or implied places for cents. 10. 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. 11. 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. 12. Front End Validation The levels of editing performed in the front-end system will be documented separately. 13. 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. 14. Service Line Charge Amounts Empire requires at least one service line other than the 0001 revenue code with a dollar amount greater than zero. 15. Revenue Codes The National Uniform Billing Committee (NUBC) defines revenue codes as a 4 position numeric field. The leading zero is a significant value and must be present. Examples: 0360 is a valid code submitted in 2400, SV is an invalid code submitted in 2400, SV 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. As an example 1.0 would be allowed. If 1.5 is present, the claim will be returned with a business edit. 17. Group Number Format Refer to the Detail Transaction Instruction section of this document for group number format. The front-end edit documentation will contain complete edit requirements on the group number. 18. Submission of Electronic Adjustments The A1 allows for the electronic submission of adjustments to previously processed claims. Empire will 3

6 GENERAL INSTRUCTIONS Item Empire Requirement apply certain business edits to insure we can facilitate the processing of electronic adjustments. 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: 2300 CLM05-3 equal to 7 or REF (REF01 equal to F8 ) 2300 REF (REF02 equal to Original Reference Number) 2300 NTE (NTE01 = ADD) 2300 NTE required when HI value equal to D HI (HI value equal to D0-D9 or E0) 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. 19. Billing Provider and Federal Tax ID Number Updated for NPI February 10, 2006 You must continue to submit the Empire assigned provider number (EPIN) until further notice. The front-end edit documentation also contains specific edit requirements for submission of electronic adjustments. Empire will process all claims which contain a valid Blue Cross Number supplied as the Billing Provider identified in the Loop 2010AA REF segment. NPI Update: Beginning February 10, 2006, Empire will allow the submission of the National Provider Identifier (NPI) IN ADDITION to the Empire assigned provider number (EPIN) If the NPI is submitted on 837 claims, the EPIN MUST continue to be submitted in REF02 of Loop 2010AA. If the NPI is submitted in the Billing Provider Loop, the billing provider Federal Tax Identification Number must be submitted in the 2010AA Billing Provider REF segment in addition to a REF segment for the Empire EPIN number. The Federal Tax Identification number will not be edited for validity at this time but will be at a later date. Please refer to the detail section of this document Loop 2010AA. The Pay-to-Provider in Loop 2010AB and the Service Facility Provider in Loop 2310E can be submitted, however, they will not be used for processing of claims. 20. Subscriber and Patient Loops Refer to the implementation guide for submission of claims when the subscriber and patient are the same and when the 4

7 GENERAL INSTRUCTIONS Item Empire Requirement subscriber and patient are different. 21. Delimiters Empire recommends using the delimiters defined in section A Character Name Delimiter * Asterisk Data Element Separator : Colon Sub-element Separator ~ Tilde Segment Terminator Use of other characters can be discussed during the testing period with trading partners. 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 300 or 303. Example, or 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 Institutional 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 (004010X096A1) 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 5

8 GENERAL INSTRUCTIONS Item Empire Requirement 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 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: 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 IG0059 Not Performed 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. 6

9 GENERAL INSTRUCTIONS Item Empire Requirement If none of the above critical errors are received, all IG edits will be performed on all segments within the ST through SE. 24. Use of Procedure Codes Use of procedure codes is not allowed on outpatient claims. Outpatient claims are defined above. All outpatient claims Updated March 2004 that contain a HI segment with qualifiers equal to BR or BQ will fail with an implementation guide edit. This requirement was documented in the Federal Register as part of the Transaction and Code Set final rule. 25. Baby Birth Weight In version 4010, the baby birth weight was identified in Loop 2000B or 2000C PAT08. The PAT segment is not used in version 4010A 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. In version 4010A1, the baby birth weight is determined from Loop 2300 HI segment (HI Qualifier equal to BE) Value code equal to 54. 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* 27. Transmission File Size Updated March 2004 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. Empire recommends sending no more than 5,000 claims per transmission. 7

10 DETAIL TRANSACTION INSTRUCTIONS This section of the document will follow the format of the implementation guide and list specific 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 elements that Empire requires to conduct it s 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. 837I Loop 837I Segment Segment/Element Empire Blue Cross Blue Shield Requirement and Element Name 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 and is validated against internal control files. Note: this will be the same value as currently reported in the UB-92, Record Type 01, Field 2, Positions The UB-92 is defined as 9(10) and is right justified and zero filled since the submitter ID is nine positions. Do not zero fill ISA06. The ISA06 value must only contain the nine position submitter ID or your file will reject for not authorized when edited against internal authorization files. ISA07 Interchange ID Qualifier Must equal ZZ. ISA08 Interchange Receiver ID Must equal If you 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 Acknowledgment 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 for Empire Blue Cross 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

11 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element Segment/Element Name Empire Blue Cross Blue Shield Requirement 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 X096A1. 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 X096A1. This transaction is being used in a production mode. To indicate if a transmission is test or production, use ISA B NM109 Receiver Primary Identifier We recommend using the same value that submitted in GS03. NPI Updated February 2006: Loop 2010AA NM108 and NM109 are required elements. With the implementation of the National Provider Identifier, either the Billing Provider Federal Tax Identification Number or the National Provider ID Number can be submitted in the NM108 or NM109 elements. If the NPI is submitted in the NM108 and NM109, then the Billing Provider Federal Tax identification number is required in Loop 2010AA, REF segment with REF01 equal to EI and REF02 equal to the billing provider Federal Tax Identification Number. The EPIN must still continue to be submitted in the 2010AA REF segment until further notice. 2010AA NM108 Identification Code Qualifier Must equal AA NM109 Billing Provider Primary ID Number Must equal the EIN value. This number is not validated. NPI - Updated February 2006 (Loop 2010AA NM1 and REF Segments) 2010AA NM108 Identification Code Qualifier Must equal XX. 2010AA NM109 Billing Provider Primary ID Number Must equal the billing provider NPI. This number is not validated at this time. 2010AA REF01 Reference Identification Qualifier Although this segment is situational in the implementation guide, Empire requires at least one REF segment with a 1A qualifier. There must be only one REF segment with a 1A qualifier. This qualifier identifies the Empire Blue Cross provider number reported in REF AA REF02 Billing Provider Secondary Identification Number If the NPI is present, the EPIN MUST still continue to be submitted until further notice or your claims will reject. This value must equal the 6 digit Empire assigned Blue Cross provider number. This number will be used for provider authorization. The front-end edit documentation will contain complete edit requirements for the Empire Blue Cross provider number. If the NPI is present, the EPIN MUST still continue to be submitted or your claims will reject. 8

12 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element Segment/Element Name 2010AA REF01 Reference Identification Qualifier 2010AA REF02 Billing Provider Secondary Identification Number 2000B SBR01 Payer Responsibility Sequence Number Code 2000B SBR03 Insured Group or Policy Number Empire Blue Cross Blue Shield Requirement When the NPI is submitted in Loop 2010AA, NM109 with NM108 equal to XX, there must be a REF segment present in Loop 2010AA with REF01 equal to EI IN ADDITION to the REF segment with REF01 equal to 1A. This value must equal the billing provider Federal Tax Identification Number. 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 an alphanumeric 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 Must equal BL. 2010BA NM102 Entity Type Qualifier Must equal BA NM108 Identification Code Qualifier Must equal MI. 2010BA NM109 Subscriber Primary Identifier Must equal the subscriber identification number as shown on Blue Cross 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 9

13 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element Segment/Element Name Empire Blue Cross Blue Shield Requirement 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. 2010BC NM108 Identification Code Qualifier Must equal PI. 2010BC NM109 Payer Identifier For Empire subscribers: The plan code must equal or For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. 2010CA NM108 Identification Code Qualifier Must equal MI. 2010CA NM109 Patient Primary Identifier 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 Cross 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 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 10

14 DETAIL TRANSACTION INSTRUCTIONS 837I 837I Segment Segment/Element Empire Blue Cross Blue Shield Requirement Loop and Element Name 2300 CLM Claim Information Empire recommends sending no more than 5,000 claims per transmission. (Updated March 2004) 2300 CLM01 Patient Account Number Empire will only store up to 20 positions for a patient control number as noted in the implementation guide CLM02 SV201and SV203 Total Claim Charge Amount Product or Service ID Qualifier Line Item Charge Amount Total claim charge amount reported in CLM02 must equal the sum of the service line total charges. If revenue code 0001 is present, the 0001 amount must equal the sum of the service line total charges. The 0001 revenue code is not required 2300 CLM05-1 Facility Type Code If CLM05-1 equals 33 or 34, then the CL103 (patient status code) must be present. Empire requires this element for the following outpatient type of bills: 33X and 34X. The implementation guide requires this element for inpatient type of bills, it does not prohibit using this element on outpatient type of bills CLM05-3 NTE01=ADD NTE02 HI Qualifier equals BG CLM05-3 NTE01=ADD NTE02 HI Qualifier equals BG Claim Frequency Code Billing Note Claim Frequency Code Billing Note (Cont.) If CLM05-3 is equal to 7 or 8 and the HI segment has a qualifier of BG and the associated value is equal to D9 then we require a 2300 NTE segment. In that segment, the qualifier in NTE01 must equal ADD and the first three positions of NTE02 must be populated with one of the following values to identify the reason for the claim adjustment: DIA, POS, UNT, MDF, DEP, SOA, MED, AUT, TDF, CDR or OTH Notes: The HI segment in Loop 2300 has a qualifier equal to BG which supports the NUBC condition codes. Condition codes D0-D9 and E0 support the reasons for claim adjustments and must be used if the adjustment reason can be defined using one of the standard codes. Definitions of Values: DIA Diagnosis POS Place of Service UNT Units of Service MDF Modifier DEP Dependent Number Change SOA Questioning Schedule of Allowance MED Medical Necessity Appeal AUT Authorization on File Appeal Denial TDF Timely Filing Denial Appeals CDR Contractual Denial Review OTH Other 2300 CLM18 Explanation of Benefits Indicator 2300 PWK01 Attachment Report Type Code The value of OTH should be used if none of the other values are appropriate. Regardless of the value submitted in this element, Empire will continue to create a paper voucher until further notice. The following values will be reviewed for Home Health Claims: 11

15 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element Segment/Element Name 2300 PWK01 (Cont) Attachment Report Type Code (Cont) Empire Blue Cross Blue Shield Requirement AS B3 CT DG DS EB NN OZ PZ RT Admission Summary Physician Order Certification Diagnostic Report Discharge Summary Explanation of Benefits Nursing Notes Support Data for Claim Physical Therapy Certification Report of tests and Report Analysis The following values will be reviewed for Alcohol/Substance Abuse Claims: AS B3 CT DG DS EB NN OZ PN RR RT Admission Summary Physician Order Certification Diagnostic Report Discharge Summary Explanation of Benefits Nursing Notes Support Data for Claim Physical Therapy Notes Radiology Films Report of tests and Report Analysis 2300 PWK02 Attachment Transmission Code 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 PWK05 Identification Code Qualifier To submit the American Express Authorization Number, the value in this element must equal AC PWK06 Attachment Control Number 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 not zero fill this element. This is not the American Express Credit Card Number. Do not send the credit card number to Empire PWK07 Attachment Description This element allows for up to 80 bytes of data per Attachment Report Type Code (PWK01). The PWK segment can be submitted up to 10 times. A total of 800 bytes of data can be submitted using any of the values in PWK01. The PWK01 value may be repeated, however, if more than 10 PWK segments are present, the claim will fail with an implementation guide edit REF Original Reference Number A REF segment with a F8 qualifier is required when 12

16 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element 2300 NTE01 CRC03- CRC07 (CRC01=75) 2300 NTE01 CRC03- CRC07 (CRC01=77) Segment/Element Name (ICN/DCN) Claim Note Claim Note 2300 NTE Billing Note NTE01=ADD Empire Blue Cross Blue Shield Requirement submitting electronic claim adjustments (CLM05-3 equal to 7 or 8). REF02 must be a minimum of 10 positions. When CRC01= 75, and CRC03-CRC07 = OL, then the 2300 NTE segment must be present. The corresponding NTE01 must equal UPI and NTE02 must be greater than spaces. When CRC01= 77, and CRC03-CRC07 = MC, then the 2300 NTE segment must be present. The corresponding NTE01 must equal UPI and NTE02 must be greater than spaces. The 837 supports electronic submission of adjustments to previously processed claims. Empire will apply certain business edits to facilitate the processing of adjustment transactions CR610 CR611 Product Service ID Qualifier (ID) Surgical Procedure Code The NTE (Billing Note) segment is required when the CLM05-3 (claim frequency) value equals 7 or 8 and the condition code reported in the HI segment (BG qualifier) is equal to D9. Decimals are not required. If decimals are present, the following format must be followed HI01-1 HI01-2 Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information Principal and Other Procedure Code Format: If the procedure code contains a decimal: The code must have two significant digits in front of the decimal There MUST be one digit following the decimal There can be a second digit following the decimal. Spaces in the second digit following the decimal is valid. HI01-1 must equal BK. HI01-2 must contain the principal diagnosis code. Empire requires a principal diagnosis code for all claims regardless of the type of bill. Must equal BR Principal Procedure Code Qualifier 2300 HI01-1 Principal Procedure Information 2300 HI Other Procedure Information Qualifier must equal BQ (repeats 12 times within segment) Other Procedure Information 2300 HI Principal Diagnosis (BK) Admitting Diagnosis (BJ) Patient Reason for Visit (ZZ) E-Code (BN) Other Diagnosis (BF) Decimals are not required. If decimals are present, the following format must be followed. Diagnosis Code, Patient Reason for Visit and Other Diagnosis Code Formats: If the diagnosis code contains a decimal: 13

17 DETAIL TRANSACTION INSTRUCTIONS 837I Loop 837I Segment and Element Segment/Element Name Empire Blue Cross Blue Shield Requirement The code must have three significant digits in front of the decimal There can be two digits following the decimal. For example: and are valid. Valid 'V' diagnosis codes would appear as V02.5 or V02.51 E-Code: Diagnosis codes which contain an 'E' in the first position: The code must have 4 digits prior to the decimal. Spaces after the decimal are considered valid. For example: E849 and E849.1 are valid. E84.91 is invalid HI Principal Procedure (BR) Other Procedure (BQ) Decimals are not required. If decimals are present, the following format must be followed. Principal and Other Procedure Code Format: If the procedure code contains a decimal: The code must have two significant digits in front of the decimal There MUST be one digit following the decimal There can be a second digit following the decimal. Spaces in the second digit following the decimal is valid. 2310A NM1 Attending Physician Name NM101 equals 71 (Attending Physician ID) This attending physician ID number is not validated. NM102 must equal 1. NM103 is required NM104 is required. NM108 Empire will accept either qualifier of 24 or 34 until the National Provider Id is implemented. 2310B NM1 Operating Physician Name NM101 equals 72 (Operating Physician ID) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Operating Physician ID number is not validated. 2310C NM1 Other Provider Name NM101 equals 73 (Operating Physician ID) Empire will accept either qualifier of 24 or 34 in NM108 until the National Provider Id is implemented. The Other Provider ID number is not validated SBR09 Claim Filing Indicator Code If value is equal to MA, then 2330B NM109 must equal B NM109 Other Payer Primary If value is equal 00308, then 2320 SBR09 must equal 14

18 DETAIL TRANSACTION INSTRUCTIONS 837I 837I Segment Segment/Element Empire Blue Cross Blue Shield Requirement Loop and Element Name Identifier MA SV202-1 Product or Service ID Must equal HC. Qualifier 2400 SV202-2 Procedure Code SV202-1 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 DTP01 =472 DTP02 Service Line Date For outpatient bills (determined by type of bill), DTP02 must equal D LIN03 National Drug Code Empire recommends that the National Drug Code be sent without any hyphens. 2420A NM1 Attending Physician Name NM101 equals 71 (Attending Physician ID) The Attending Physician ID number is not validated. NM102 must equal 1. NM103 is required NM104 is required. NM108 Empire will accept either qualifier of 24 or 34 until the National Provider Id is implemented. 15