837 Healthcare Claim Companion Guide ANSI ASC X12N (Version 4010A) Professional, Institutional, and Dental

Transcription

1 837 Healthcare Claim Companion Guide ANSI ASC X12N (Version 4010A) Professional, Institutional, and Dental State of Washington Department of Social & Health Services Prepared by: CNSI 3000 Pacific Avenue S.E. Suite 200 Olympia, Washington April 14, 2009

2 837 Healthcare Claim Companion Guide ANSI ASC X12N (Version 4010A) Professional, Institutional, and Dental State of Washington Department of Social & Health Services April 14, 2009 Approved By: CNSI Project Manager DSHS Project Manager Date Date Disclaimer This companion guide for the ANSI ASC X12N 837 transaction has been created for use in conjunction with the standard Implementation Guide. It should not be considered a replacement for the Implementation Guide, but rather used as an additional source of information. The companion guide contains data clarifications derived from specific business rules that apply exclusively to Medicaid processing for Washington State DSHS. The guide also includes useful information about sending and receiving data to and from the ProviderOne system.

3 Revision History Documented revisions are maintained in this document through the use of the Revision History Table shown below. All revisions made to this companion guide after the creation date are noted along with the date, page affected, and reason for the change. Revision Level Date Page Description Change Summary WAMMIS-CG WAMMIS-CG WAMMIS-CG WAMMIS-CG- 837CLAIMS WAMMIS-CG- 837CLAIMS WAMMIS-CG- 837CLAIMS WAMMIS-CG- 837CLAIMS WAMMIS-CG- 837CLAIMS WAMMIS-CG- 837CLAIMS /02/08 Initial Document 04/17/08 Internal CNSI comments incorporated 05/15/08 Incorporated comments from DSHS review 06/28/08 Final Delivery 07/16/08 Re-Delivery of the Deliverable based on DSHS non- Acceptance and identification of deficiencies 07/25/08 Re-Delivery of the Deliverable based on DSHS non- Acceptance and identification of deficiencies 08/06/08 Re-Delivery of Deliverable based on CR from DSHS 10/01/08 Re-Delivery of the Deliverable based on DSHS suggested changes to Trading Partners Testing Procedures verbiage 04/14/09 Changes to verbiage and rules post UAT Use generic language in the Claim Note segment in transaction specification Update 837 Companion Guide based on CR Claims The 837 Institutional Companion Guide and ProviderOne must be updated to allow for additional claim frequency type codes (CFTC) from the UB-04 manual. iii

4 Contents Disclaimer... ii Revision History... iii 1 Introduction Document Purpose Intended Users Relationship to HIPAA Implementation Guides Transmission Schedule Technical Infrastructure and Procedures Technical Environment Communication Requirements Testing Process Who to contact for assistance Upload batches via Web Interface Set-up, Directory, and File Naming Convention SFTP Set-up SFTP Directory Naming Convention File Naming Convention Transaction Standards General Information Data Format Data Interchange Conventions Acknowledgement Procedures Rejected Transmissions and Transactions Transaction Specifications iv

5 1 Introduction The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) includes requirements that national standards be established for electronic health care transactions, and national identifiers for providers, health plans, and employers. This requires Washington State Department of Social and Health Services (DSHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions between covered entities (health care providers, health plans, and healthcare clearinghouses). The intent of these standards is to improve the efficiency and effectiveness of the nation's health care system by encouraging widespread use of electronic data interchange standards in health care. The intent of the law is that all electronic transactions for which standards are specified must be conducted according to the standards. These standards were not imposed arbitrarily but were developed by processes that included significant public and private sector input. 1.1 Document Purpose Companion Guides are used to clarify the exchange of information on HIPAA transactions between the DSHS ProviderOne system and its trading partners. DSHS defines trading partners as covered entities that either submit or retrieve HIPAA batch transactions to and from ProviderOne. This Companion Guide provides information related to electronic submission of 837 Claims Transactions to DSHS by approved trading partners. The three distinct claim transaction formats documented are: 837 Professional (Claims and Encounters) 837 Institutional (Claims and Encounters) 837 Dental This Companion Guide is intended for trading partner use in conjunction with the ANSI ASC X12N National Implementation Guides listed below. The ANSI ASC X12N Implementation Guides can be accessed at The Standard Implementation Guides for Claim Transactions are: 837 Healthcare Claim: Professional (004010X098) 837 Healthcare Claim: Institutional (004010X096) 837 Healthcare Claim: Dental (004010X097) 5

6 DSHS has also incorporated all of the approved 837 Addenda listed below. ASC X12N 837 Professional (004010X098A1) ASC X12N 837 Institutional (004010X096A1) ASC X12N 837 Dental (004010X097A1) Intended Users Companion Guides are intended to be used by members/technical staff of trading partners who are responsible for electronic transaction/file exchanges Relationship to HIPAA Implementation Guides Companion Guides are intended to supplement the HIPAA Implementation Guides for each of the HIPAA transactions. Rules for format, content, and field values can be found in the Implementation Guides. This Companion Guide describes the technical interface environment with DSHS, including connectivity requirements and protocols, and electronic interchange procedures. This guide also provides specific information on data elements and the values required for transactions sent to or received from DSHS. Companion Guides are intended to supplement rather than replace the standard Implementation Guide for each transaction set. The information in these documents is not intended to: Modify the definition, data condition, or use of any data element or segment in the standard Implementation Guides. Add any additional data elements or segments to the defined data set. Utilize any code or data values that are not valid in the standard Implementation Guides. Change the meaning or intent of any implementation specifications in the standard Implementation Guides. 1.2 Transmission Schedule N/A 6

7 2 Technical Infrastructure and Procedures 2.1 Technical Environment Communication Requirements This section will describe how trading partners can send 837 Transactions to DSHS using 2 methods: Secure File Transfer Protocol (SFTP) ProviderOne Web Portal Testing Process Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne. Testing is conducted to ensure the following levels of HIPAA compliance: 1. Level 1 Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. 2. Level 2 Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. 3. Level 7 DSHS defined custom rules. All transactions will be validated against DSHS defined custom rules as specified in the Transaction Specification section. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the ANSI formats may also require additional testing. Assistance is available throughout the testing process. Trading Partner Testing Procedures 1. ProviderOne companion guides and trading partner enrollment package are available for download via the web at 2. The Trading Partner completes the Trading Partner Agreement and submits the signed agreement to DSHS. Submit to: Provider Enrollment 7

8 PO Box Olympia, WA **For Questions call option 2, then option 5** 3. The trading partner is assigned a Submitter ID, Domain, Logon User ID and password. 4. The trading partner submits all HIPAA test files through the ProviderOne web portal or Secure File Transfer Protocol (SFTP). Web Portal URL: SFTP URL: sftp://ftp.waproviderone.org/ 5. The trading partner downloads acknowledgements for the test file from the ProviderOne web portal or SFTP. 6. If ProviderOne system generates a positive TA1 and positive 997 acknowledgement, the file is successfully accepted. The trading partner is then approved to send 837 HIPAA files in production. 7. If the test file generates a negative TA1 or negative 997 acknowledgment, then the submission is unsuccessful and the file is rejected. The trading partner needs to resolve all the errors that are reported on the negative TA1 or negative 997 and resubmit the file for test. Trading partners will continue to test in the testing environment until they receive a positive TA1 and positive Who to contact for assistance Telephone Number: Select option 2 Select option 4 o All calls result in the assignment of a Ticket Number for problem tracking Hours: 8:00 AM 5:00 PM Pacific Standard Time, Monday through Friday Information required for initial call: o Topic of Call (setup, procedures, etc.) o Name of caller o Submitter ID Number o Organization of caller o Telephone number of caller o Nature of problem (connection, receipt status, etc.) Information required for follow up call(s): o Assigned Ticket Number 8

9 2.2 Upload batches via Web Interface Once logged into the ProviderOne Portal, select the Admin Tab and the following options will be presented to the user: Click on the HIPAA option to manage the HIPAA transactions. 9

10 In the HIPAA Transaction Management screen, the user can Upload file and Retrieve Acknowledgement/Response as shown below: 10

11 In order to upload a file, the following steps are followed: Click on the Upload button to upload a HIPAA file On file upload page click on the Browse button to attach HIPAA file from local file system. After selecting the file from the local file system, press OK to start the upload. 11

12 Once the file is uploaded to the ProviderOne system success/failure message is displayed on the screen along with transmission details. 12

13 Select Retrieve Acknowledgement/Response option from the HIPAA screen to retrieve Acknowledgements/Responses (TA1, 997, 271, 277, 820, 834, 835, or 277U) as shown below: 13

14 2.3 Set-up, Directory, and File Naming Convention SFTP Set-up Trading partners can contact for information on establishing connections through the FTP server. Upon completion of set-up, they will receive additional instructions on FTP usage SFTP Directory Naming Convention There would be two categories of folders under Trading Partner s SFPT folders: 1. TEST Trading Partners should submit and receive their test files under this root folder 2. PROD Trading Partners should submit and receive their production files under this root folder Following folder will be available under TEST/PROD folder within SFTP root of the Trading Partner: HIPAA_Inbound - This folder should be used to drop the Inbound files that needs to be submitted to DSHS HIPAA_Ack - Trading partner should look for acknowledgements to the files submitted in this folder. TA1, 997 and custom error report will be available for all the files submitted by the Trading Partner HIPAA_Outbound X12 outbound transactions generated by DSHS will be available in this folder HIPAA_Error Any inbound file that is not HIPAA compliant or is not recognized by ProviderOne will be moved to this folder 14

15 Folder structure will appear as: File Naming Convention The HIPAA Subsystem Package is responsible for assisting ProviderOne activities related to Electronic Transfer and processing of Health Care and Health Encounter Data, with a few exceptions or limitations. HIPAA files are named: For Inbound transactions: HIPAA.<TPId>.<datetimestamp>.<originalfilename>.<dat> Example of file name: HIPAA _P_1.dat <TPId> is the Trading Partner Id <datetimestamp> is the Date timestamp <originalfilename> is the original file name which is submitted by the trading partner. 2.4 Transaction Standards General Information HIPAA standards are specified in the Implementation Guide for each mandated transaction and modified by authorized Addenda. Currently, the 837 transaction has one Addendum. This Addendum has been adopted as final and is incorporated into DSHS requirements. 15

16 An overview of requirements specific to the transaction can be found in the 837 Implementation Guide. Implementation Guides contain information related to: Format and content of interchanges and functional groups Format and content of the header, detailer and trailer segments specific to the transaction sets and values authorized for use in the transaction Allowed exceptions to specific transaction requirements Transmission sizes are limited based on two factors: Number of Segments/Records allowed by DSHS DSHS file size limitations DSHS limits the size of the transaction (ST-SE envelope) to a maximum of 5,000 CLM segments. DSHS limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through FTP Data Format Delimiters The ProviderOne will use the following delimiters on outbound transactions: Dates Data element separator - Asterisk ( * ) Sub-element Separator - colon ( : ) Segment Terminator - Tilde ( ~ ) The following rules apply to any dates in the 837 transaction: For the 837 Professional and Dental all dates will be formatted according to Year 2000 compliance, CCYYMMDD, except for the ISA09 element where the date format is YYMMDD. For the 837 Institutional all dates will be formatted according to Year 2000 compliance, CCYYMMDD, except for the ISA09 element where 16

17 the date format is YYMMDD and the Admission Date/Hour where the date format is CCYYMMDDHHMM. The only value acceptable for "CC" (century) is 20. The exception to this rule is for any of the Date of Birth values. Time is in military time format, 1 to 24 to indicate hours and 00 to 59 to indicate minutes and/or seconds. ISA10 and GS05 elements are formatted HHMM (ie 2115 defines the time of 9:15 p.m). BGN04 element is HHMMSS (ie defines the time of 9:15:15 p.m.). No spaces or character delimiters should be used in presenting dates or times. Dates that are logically invalid (e.g ) are rejected. Field Length HIPAA regulations specify field lengths for all of the data elements of the 837 Healthcare Claim transaction. For some of these data elements, ProviderOne processes fewer characters than the maximum allowed. The Transaction Specifications in section 3 display the ProviderOne field lengths. Phone Numbers Phone numbers are presented as contiguous number strings, without dashes or parenthesis markers. For example, the phone number (800) should be presented as Area codes should always be included Data Interchange Conventions When accepting 837 Healthcare Claim transactions from trading partners, DSHS follows standards developed by the Accredited Standards Committee (ASC) of the American National Standards Institute (ANSI). These standards involve Interchange (ISA/IEA) and Functional Group (GS/GE) Segments or outer envelopes. All 837 Transactions should follow the HIPAA guideline. Please refer to the 837 Implementation Guide for ISA/IEA envelop, GS/GE functional group and ST/SE transaction specifications. Specific information on how individual data elements are populated by DSHS on ISA/IEA and GS/GE envelopes are shown in the table beginning later in this section. The ISA/IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length. Example of ISA with the entire data length with padded spaces: 17

18 ISA*00* *00* *ZZ* *ZZ*77045 *040303*1300*U*00401* *1*T*:~ DSHS accepts 837 transaction files with single ISA/IEA and GS/GE envelopes. 837 transactions (with their limit of 5,000 CLM segments within an ST/SE envelop), can have multiple ST/SE envelops within the same GS/GE envelope Acknowledgement Procedures Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 997 acknowledgment transactions will be placed in appropriate folder (on the FTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 997 acknowledgement, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files, which do not meet the HIPAA standards a negatvie TA1 and/or negative 997 are generated and sent to the trading partner Rejected Transmissions and Transactions 837 Healthcare Claims will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2). Additionally, the transactions will be validated against DSHS defined custom rules (SNIP type 7) as specified in the Transaction Specification section. Non-compliance of the custom rules will result in rejection of the transaction. 18

19 3 Transaction Specifications 837 PROFESSIONAL Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER App. B ENVELOPE ISA 01 Authorization Information App. B ENVELOPE ISA 02 Authorization Information App. B ENVELOPE ISA 03 Security Information App. B ENVELOPE ISA 04 Security Information App. B ENVELOPE ISA 05 Interchange ID App. B ENVELOPE ISA 06 Interchange Sender ID App. B ENVELOPE ISA 07 Interchange ID App. B ENVELOPE ISA 08 Interchange Receiver ID '00' 10 spaces '00' 10 spaces 'ZZ' the 9- digit ProviderOne ID 'ZZ' '77045' followed by spaces App. B ENVELOPE ISA 09 Interchange Date Date format is YYMMDD App. B ENVELOPE ISA 10 Interchange Time Time format is HHMM App. B ENVELOPE ISA 11 Interchange Control Standards Identifier Use 'U' 19

20 Page Loop Segment Data Element Element Name Comments App. B ENVELOPE ISA 12 Interchange Control Version Number App. B ENVELOPE ISA 13 Interchange Control Number App. B ENVELOPE ISA 14 Acknowledgment Requested Use '00401' Must be identical to IEA02 '1' App. B ENVELOPE ISA 15 Usage Indicator 'T' when submitting a Test File 'P' when submitting a Production File App. B ENVELOPE ISA 16 Component Element Separator ':' 20

21 FUNCTIONAL GROUP HEADER App. B ENVELOPE GS 01 Functional Identifier App. B ENVELOPE GS 02 Application Sender s App. B ENVELOPE GS 03 Application Receiver s Use 'HC' the 9- digit ProviderOne ID. This should be same as ISA06 and Loop 1000A, Data Element NM109 '77045' App. B ENVELOPE GS 04 Date Date format is CCYYMMDD App. B ENVELOPE GS 05 Time Time format is HHMM App. B ENVELOPE GS 06 Group Control Number App. B ENVELOPE GS 07 Responsible Agency App. B ENVELOPE GS 08 Version / Release / Industry Identifier Must be identical to GE02 Use 'X' Use '004010X098A1' TRANSACTION SET HEADER 61 HEADER ST 01 Transaction set identifier code 61 HEADER ST 02 Transaction set control number '837' Must be identical to SE02 Beginning of Hierarchical Transaction 21

22 62 HEADER BHT 01 Hierarchical Structure 63 HEADER BHT 02 Transaction Set Purpose Use '0019' '00' 63 HEADER BHT 03 Originator Application Transaction Identifier Reference 63 HEADER BHT 04 Transaction Set Creation Date 64 HEADER BHT 05 Transaction Set Creation Time 64 HEADER BHT 06 Claim or Encounter Indicator Transaction Type Date Format is CCYYMMDD Time Format is HHMM CH Transmission Type 65 HEADER REF 01 Reference 65 HEADER REF 02 Transmission Type Reference Use '87' X098DA1 when submitting Test File '004010X098A1' when submitting Production File Loop ID 1000A - Submitter Name A NM1 101 Entity Identifier Use '41' 22

23 23

24 A NM1 02 Entity Type A NM1 03 Last Name or Organization Name appropriate Submitters Last or Organization Name A NM1 04 Name First Required if NM102 = A NM1 08 Use '46' A NM1 09 the 9- digit ProviderOne ID. Submitter EDI Contact Information This should be same as ISA06 and GS A PER 01 Contact Function Use 'IC' A PER 02 Name Submitter Contact Name A PER 03 Communication Number A PER 04 Communication Number A PER 05 Communication Number A PER 06 Communication Number 'TE' Submitter Contact Phone Number 'EM' Submitter Contact Address 24

25 Loop ID 1000B - Receiver Name B NM1 01 Entity Identifier B NM1 02 Entity Type B NM1 03 Name Last or Organization Name B NM1 08 Use '40' Use '2' 'WA State DSHS' Use '46' B NM Loop ID 2000A - Billing/Pay-To Provider Hierarchical Level A HL 01 Hierarchical ID Number A HL 03 Hierarchical Level A HL 04 Hierarchical Child Use '20' Use '1' Billing/Pay-To Provider Specialty Information A PRV 01 Provider appropriate code If 'BI' is used than the taxonomy code will be applied to the Billing Provider in 2010AA If 'PT' is used, than the taxonomy code will be applied to the Pay-To Provider in 25

26 2010AB A PRV 02 Reference A PRV 03 Provider Taxonomy (Specialty ) Reference Use 'ZZ' Provider Taxonomy Loop ID 2010AA - Billing Provider Name AA NM1 01 Entity Identifier AA NM1 02 Entity Type AA NM1 03 Last Name or Organization Name Use '85' appropriate code Billing Provider Last or Organizational Name AA NM1 04 First Name Required if NM102 = AA NM1 08 code qualifier For Healthcare Providers please use 'XX' For Atypical Providers who are not required to have an NPI please use one of the following qualifiers: 24 - Employer ID 34 - SSN 26

27 AA NM1 09 code Billing Provider NPI if NM108 = 'XX' Employer Number or Social Security Number of Billing Provider if NM108 = '24' or '34' Billing Provider Address AA N3 01 Address Information Address of Billing Provider AA N3 02 Address Information Billing Provider City/State/Zip AA N4 01 City Name City Name of Billing Provider AA N4 02 State or Province State of Billing Provider AA N4 03 Postal Zip of Billing Provider Billing Provider Secondary Info AA REF 01 Reference 'EI' or 'SY' if NM108 = 'XX' '1D' if NM108 = '24' or '34' 27

28 AA REF 02 Reference Employers Number or Social Security Number of Billing Provider if REF01 = 'EI' or 'SY' 9 digit alphanumeric ProviderOne ID if REF01 = '1D' Billing Provider Contact Information Required if this information is different than that contained in the Loop 1000A - Submitter PER Segment. If different, please use the following guidelines AA PER 01 Contact Function Use 'IC' AA PER 02 Name Billing Provider Contact Name AA PER 03 Communication Number AA PER 04 Communication Number AA PER 05 Communication Number AA PER 06 Communication Number 'TE' Billing Provider Contact Phone Number 'EM' Billing Provider Contact Address 28

29 Loop ID 2010AB - Pay-To Provider Name Required if the Pay-to Provider is a different entity than the Billing Provider. If different, please use the following guidelines. If used, please use 'PT' in Loop 2000A, Data Element PRV AB NM1 01 Entity Identifier AB NM1 02 Entity Type AB NM1 03 Last Name or Organization Name Use '87' appropriate code Pay-To Provider Last or Organizational Name AB NM1 04 First Name Required if NM102 = AB NM1 08 code qualifier For Healthcare Providers please use 'XX' For Atypical Providers who are not required to have an NPI please use one of the following qualifiers: 24 - Employer ID 34 - SSN 29

30 AB NM1 09 code Pay-To Provider NPI if NM108 = 'XX' Employer Number or Social Security Number of Pay-To Provider if NM108 = '24' or '34' Pay-to Provider Address AB N3 01 Address Information Address of Pay-To Provider AB N3 02 Address Information Pay-to Provider City/State/Zip AB N4 01 City Name City Name of Pay-To Provider AB N4 02 State or Province State of Pay-To Provider AB N4 03 Postal Zip of Pay-To Provider Pay-to Provider Secondary Information AB REF 01 Reference 'EI' or 'SY' if NM108 = 'XX' '1D' if NM108 = '24' or '34' 30

31 AB REF 02 Reference Employers Number or Social Security Number of Billing Provider if REF01 = 'EI' or 'SY' 9 digit alphanumeric ProviderOne ID if REF01 = '1D' Loop ID 2000B - Subscriber Hierarchical Level B HL 01 Hierarchical ID Number B HL 02 Hierarchical Parent ID Number B HL 03 Hierarchical Level B HL 04 Hierarchical Child Use '22' appropriate code 31

32 Subscriber Information B SBR 01 Payer Responsibility Sequence Number B SBR 02 Individual Relationship B SBR 09 Claim Filing Indicator appropriate Use '18' 'MC' Loop ID 2010BA - Subscriber Name BA NM1 01 Entity Identifier BA NM1 02 Entity Type BA NM1 03 Last Name or Organization Name Use 'IL' '1' Last Name of Subscriber BA NM1 04 First Name First Name of Subscriber BA NM1 08 code qualifier 'MI' BA NM1 09 code 11 digit ProviderOne Client ID ProviderOne Client ID is 9 numeric digits followed by 'WA' Example is WA 32

33 Subscriber Address BA N3 01 Address Information Address of Subscriber BA N3 02 Address Information Subscriber City/State/Zip BA N4 01 City Name City Name of Subscriber BA N4 02 State or Province State of Subscriber BA N4 03 Postal Zip of Subscriber Subscriber Demographic Information BA DMG 01 Date Time Period Format BA DMG 02 DOB Date Time Period Use 'D8' Subscriber Date of Birth BA DMG 03 Gender Gender of Subscriber Loop ID 2010BB - Payer Name BB NM1 01 Entity Identifier BB NM1 02 Entity Type BB NM1 03 Name Last or Organization Name Use 'PR' Use '2' 'WA State DSHS' 33

34 BB NM1 08 'PI' BB NM1 09 '77045' Payer Address BB N3 01 Address Information BB N3 02 Address Information 'Claims Processing' 'PO BOX 9248' Payer City/State/Zip BB N4 01 City Name 'Olympia' BB N4 02 State or Province 'WA' BB N4 03 Postal '98504' Loop ID Claim Information CLM 01 Patient Account Number Claim Submitter's Identifier CLM 02 Total Claim Charge Amount Monetary Amount Patient Account Number Total Claim Charge Amount CLM 05-1 Facility Value Place of Service from Source

35 CLM 05-3 Claim Frequency Type appropriate Claim Frequency Type below: 1 - Original 7 - Replacement/Adjust ment 8 - Void CLM 06 Provider signature on file flag Yes/No Condition or Response CLM 07 Provider Accept Assignment CLM 08 Benefits Assignment Certification Indicator Yes/No Condition or Response CLM 09 Release of Info code appropriate code appropriate code appropriate code appropriate code Patient Paid Amount the following guidelines if the Patient Paid Amount is necessary to adjudicate the claim AMT 01 Amount AMT 02 Patient Paid Amount Monetary Amount Use 'F5' Patient Amount Paid 35

36 Prior Authorization or Referral Number the following guidelines if the Prior Authorization Number is necessary to adjudicate the claim REF 01 Reference REF 02 Reference 'G1' Prior Authorization Number Original Reference Number (ICN/DCN) Required if CLM05-3 is a '7' or '8'. If applicable, please use the following guidelines REF 01 Reference REF 02 Reference Use 'F8' 21 digit Transaction Control Number (TCN) of claim Claim Note the following guidelines if Claim Notes are necessary to adjudicate the claim NTE 01 Note reference code appropriate code 36

37 NTE 02 Description claim notes. This field is 80 bytes in length. Health Care Diagnosis Do not transmit the decimal points in the diagnosis codes. The decimal is assumed HI 01 Health Care Information(Qualifi er, Industry ) HI 01-1 List Use 'BK' HI 01-2 Industry Principal Diagnosis HI 02 Health Care Information(Qualifi er, Industry ) the following guidelines if additional diagnosis codes need to be reported HI 02-1 List Repeat as necessary Use 'BF' HI 02-2 Industry Diagnosis HI 03 Health Care Information(Qualifi er, Industry ) HI 03-1 List HI 03-2 Industry 37

38 HI 04 Health Care Information(Qualifi er, Industry ) HI 04-1 List HI 04-2 Industry HI 05 Health Care Information(Qualifi er, Industry ) HI 05-1 List HI 05-2 Industry HI 06 Health Care Information(Qualifi er, Industry ) HI 06-1 List HI 06-2 Industry HI 07 Health Care Information(Qualifi er, Industry ) HI 07-1 List HI 07-2 Industry HI 08 Health Care Information(Qualifi er, Industry ) 38

39 HI 08-1 List HI 08-2 Industry Loop ID 2310A - Referring Provider Name the following guidelines if the Referring Provider information is necessary to adjudicate the claim A NM1 01 Entity Identifier A NM1 02 Entity Type A NM1 03 Last Name or Organization Name 'DN' appropriate code Referring Provider Last or Organization Name A NM1 04 First Name Required if NM102 = A NM1 08 code qualifier For Healthcare Providers please use 'XX' A NM1 09 code Referring Provider NPI 39

40 Referring Provider Secondary A REF 01 Reference A REF 02 Reference For Atypical Providers who are not required to have an NPI please use '1D' 9 digit alphanumeric ProviderOne ID Loop ID 2310B - Rendering Provider Name the following guidelines if the Rendering Provider information is necessary to adjudicate the claim B NM1 01 Entity Identifier B NM1 02 Entity Type B NM1 03 Last Name or Organization Name Use '82' appropriate code Rendering Provider Last or Organizational Name B NM1 04 First Name Required if NM102= B NM1 08 code qualifier For Healthcare Providers please use 'XX' B NM1 09 code Rendering Provider NPI 40

41 Rendering Provider Specialty Information B PRV 01 Provider Use 'PE' B PRV 02 Reference B PRV 03 Provider Taxonomy (Specialty ) Use 'ZZ' Rendering Provider Taxonomy Rendering Provider Secondary B REF 01 Reference B REF 02 Reference For Atypical providers who are not required to have an NPI please use '1D' 9 digit alphanumeric ProviderOne ID Loop ID Other Subscriber Information the following guidelines if Other Subscriber Information is necessary to adjudicate the claim 41

42 SBR 01 Payer Responsibility sequence Number SBR 02 Individual Relationship code SBR 03 Group or Policy Number Reference SBR 04 Group or Plan Name appropriate code '18' Subscriber Group or Policy Number Required if the subscriber s other payer identification includes Group or Plan Number Subscriber Insured Group or Plan Name Required if the subscriber s other payer identification includes Group or Plan Name SBR 05 Insurance Type code SBR 09 Claim filing indicator code Use 'MB' when submitting Medicare Crossover Claims otherwise use 'C1' Use 'MB' when submitting Medicare Crossover Claims otherwise use 'MC' Coordination Of Benefits (COB) Payer Paid Amount AMT 01 Amount Use 'D' 42

43 AMT 02 Monetary Amount Paid Amount by Medicare or Other Payer Coordination Of Benefits (COB) Approved Amount AMT 01 Amount AMT 02 Approved Monetary Amount Use 'AAE' Approved Amount by Medicare or Other Payer Coordination Of Benefits (COB) Allowed Amount AMT 01 Amount AMT 02 Allowed Monetary Amount Use 'B6' Allowed Amount by Medicare or Other Payer Coordination Of Benefits (COB) Patient Paid Amount AMT 01 Amount AMT 02 Patient Paid Monetary Amount 'F5' Medicare or Other Payer Patient Paid Amount Subscriber Demographic Information DMG 01 Date Time Period Format DMG 02 DOB Date Time Period Use 'D8' Subscriber's Date of Birth 43

44 DMG 03 Gender Gender of Subscriber Other Insurance Coverage Information OI 03 Yes/No Condition or Response appropriate code OI 04 Patient Signature Source OI 06 Release of Information appropriate code Loop ID 2330A - Other Subscriber Name A NM1 01 Entity Identifier A NM1 02 Entity Type A NM1 03 Last Name or Organization Name Use 'IL' '1' Subscriber Last Name A NM1 04 First Name Subscriber First Name A NM1 08 code qualifier 'MI' A NM1 09 code Subscriber Primary Identifier Other Subscriber Address A N3 01 Address Information Subscriber Address A N3 02 Address Information 44

45 Other Subscriber City/State/Zip A N4 01 City Name City Name of Subscriber A N4 02 State or Province State of Subscriber A N4 03 Postal Zip of Subscriber Loop ID 2330B - Other Payer Name Do not indicate Medicaid here. Only report information on other payers if known B NM1 01 Entity Identifier B NM1 02 Entity Type B NM1 03 Last Name or Organization Name B NM1 08 code qualifier Use 'PR' Use '2' Medicare or Other Payer Organization Name 'PI' B NM1 09 code Medicare or Other Payer Primary Identifier Claim Adjudication Date B DTP 01 Date/Time Use '573' B DTP 02 Date Time Period Format Use 'D8' 45

46 B DTP 03 Date Time Period Claim Paid Date by Medicare or Other Payer Other Payer Secondary B REF 01 Reference B REF 02 Reference 'F8' the Medicare or Other Payer claim number Loop ID Service Line LX 01 Line Counter Assigned Number Professional Service SV Product/Service ID 'HC' SV Product/Service I Procedure SV Procedure Modifier If applicable, please enter as many Procedure Modifiers as necessary SV Procedure Modifier SV Procedure Modifier SV Procedure Modifier SV1 02 Submitted charge Monetary amount Line Item Charge Amount 46

47 SV1 03 Unit or Basis for Measurement 'UN' SV1 04 Quantity Procedure count. Do not use decimals SV1 05 Facility Value Place of Service from code source 237 Required if value is different than value carried in Loop 2300, Data Element CLM SV Diagnosis Pointer SV Diagnosis Pointer Diagnosis Pointer If applicable, please enter additional Diagnosis Pointers SV Diagnosis Pointer SV Diagnosis Pointer 47

48 Service Date DTP 01 Date Time Use '472' DTP 02 Date Time Period Format appropriate code DTP 03 Service Date Service Date Prior Authorization Or Referral Number Required if service line involved a Prior Authorization number that is different than the number reported at the claim level in Loop If different, please use the following guidelines REF 01 Reference REF 02 Reference 'G1' Prior Authorization Number Line Item Control Number DSHS strongly encourages the use of this segment REF 01 Reference REF 02 Reference Use '6R' Line Item Control Number 48

49 Approved Amount If different than Approved Amount in Loop 2320 please use the following guidelines AMT 01 Amount Use 'AAE' AMT 02 Approved Amount Service Line Approved Amount by Medicare or Other Payer Line Note the following guidelines if Claim Notes at the line level are necessary to adjudicate the claim NTE 01 Note Reference NTE 02 Claim Note Text Description appropriate code claim notes. This field is 80 bytes in length. Loop ID 2410A - Drug the following guidelines if the NDC information is necessary to adjudicate the claim A LIN 02 Product/Service ID Use 'N4' 49

50 A LIN 03 National Drug Product/Service ID National Drug (NDC) in format Drug Pricing the following guidelines if additional NDC information is necessary to adjudicate the claim A CTP 03 Drug Unit Price Drug Unit Price A CTP 04 National Drug Unit Count Quantity A CTP 05-1 Unit/Basis for Measurement National Drug Unit Count appropriate code Loop ID 2420A - Rendering Provider Name Required if the Rendering Provider information is different than that carried in the 2310B claim loop. If different, please use the following guidelines A NM1 01 Entity Identifier A NM1 02 Entity Type A NM1 03 Last Name or Organization Name Use '82' appropriate code Rendering Provider Last or Organizational Name A NM1 04 First Name Required if NM102=1 50

51 A NM1 08 Reference code qualifier For Healthcare Providers please use 'XX' A NM1 09 Reference code Rendering Provider NPI Rendering Provider Specialty Information A PRV 01 Provider Use 'PE' A PRV 02 Reference A PRV 03 Provider Taxonomy (Specialty ) Use 'ZZ' Rendering Provider Taxonomy Rendering Provider Secondary A REF 01 Reference A REF 02 Reference For Atypical Providers who are not required to have an NPI please use '1D' 9 digit alphanumeric ProviderOne ID 51

52 Loop ID 2420F - Referring Provider Name Required if the Referring Provider information is different than that carried in the 2310A claim loop. If different, please use the following guidelines F NM1 01 Entity Identifier F NM1 02 Entity Type F NM1 03 Last Name or Organization Name 'DN' Use '1' Referring Provider Last Name F NM1 04 First Name Referring Provider First Name F NM1 08 code qualifier For Healthcare Providers please use 'XX' F NM1 09 code Referring Provider NPI 52

53 Referring Provider Secondary F REF 01 Reference For Atypical Providers who are not required to have an NPI please use '1D' F REF 02 Reference 9 digit alphanumeric ProviderOne ID Service Line Adjudication Information the following guidelines if claim has been previously adjudicated by payer identified in Loop 2330B and service line has adjustments applied to it SVD 01 Payer Identifier SVD 02 Monetary Amount Service Line Paid Amount SVD 03-1 Product /Service ID HC SVD 03-2 Product/Service ID code SVD 05 Quantity quantity Line Adjustment Submitters should use this CAS segment if the payer identified in Loop 2330B made line level adjustments which caused the amount paid to differ from the amount originally charged CAS 01 Claim Adjustment Group appropriate code CAS 02 Claim Adjustment 53

54 Reason appropriate CARC CAS 03 Monetary Amount Adjustment Amount CAS 04 Quantity quantity REPEAT THRU CAS19 IF NECESSARY Line Adjudication Date the following guidelines if the Line Adjudication Date is different than the Claim Adjudication Date carried in the 2330B claim loop DTP 01 Date/Time Use '573' DTP 02 Date Time Period Format Use 'D8' DTP 03 Date Time Period Line Adjudication Date TRANSACTION SET TRAILER 551 Trailer SE 01 Number of Included Segments 551 Trailer SE 02 Transaction Set Control Number The total number of segments in the transaction set inclusive to the ST- SE segments Must be identical to ST02 54

55 FUNCTIONAL GROUP TRAILER App.B Trailer GE 01 Number of Transaction Sets Included App.B Trailer GE 02 Group Control Number Must be identical to GS06 INTERCHANGE CONTROL TRAILER App.B Trailer IEA 01 Number of Included Functional Groups App.B Trailer IEA 02 Interchange Control Number Must be identical to ISA13 55

56 837 INSTITUTIONAL Page Loop Segment Data Element Element Name Comments INTERCHANGE CONTROL HEADER App.B ENVELOPE ISA 01 Authorization Information App.B ENVELOPE ISA 02 Authorization Information App.B ENVELOPE ISA 03 Security Information App.B ENVELOPE ISA 04 Security Information App.B ENVELOPE ISA 05 Interchange ID App.B ENVELOPE ISA 06 Interchange Sender ID App.B ENVELOPE ISA 07 Interchange ID App.B ENVELOPE ISA 08 Interchange Receiver ID '00' 10 spaces '00' 10 spaces 'ZZ' the 9- digit ProviderOne ID 'ZZ' '77045' followed by spaces App.B ENVELOPE ISA 09 Interchange Date Date format is YYMMDD App.B ENVELOPE ISA 10 Interchange Time Time format is HHMM App.B ENVELOPE ISA 11 Interchange Control Standards Identifier App.B ENVELOPE ISA 12 Interchange Control Version Number Use 'U' Use '00401' 56

57 Page Loop Segment Data Element Element Name App.B ENVELOPE ISA 13 Interchange Control Number App.B ENVELOPE ISA 14 Acknowledgment Requested Comments Must be identical to IEA02 '1' App.B ENVELOPE ISA 15 Usage Indicator 'T' when submitting a Test File 'P' when submitting a Production File App.B ENVELOPE ISA 16 Component Element Separator ':' FUNCTIONAL GROUP HEADER App.B ENVELOPE GS 01 Functional Identifier App.B ENVELOPE GS 02 Application Sender s App.B ENVELOPE GS 03 Application Receiver s Use 'HC' the 9- digit ProviderOne ID. This should be same as ISA06 and Loop 1000A, Data Element NM109 '77045' App.B ENVELOPE GS 04 Date Date format is CCYYMMDD App.B ENVELOPE GS 05 Time Time format is HHMM App.B ENVELOPE GS 06 Group Control Number Must be identical to GE02 57

58 Page Loop Segment Data Element Element Name App.B ENVELOPE GS 07 Responsible Agency App.B ENVELOPE GS 08 Version / Release / Industry Identifier Use 'X' Comments Use '004010X096A1' TRANSACTION SET HEADER 56 HEADER ST 01 Transaction set identifier code 56 HEADER ST 02 Transaction set control number '837' Must be identical to SE02 Beginning of Hierarchical Transaction 57 HEADER BHT 01 Hierarchical Structure 58 HEADER BHT 02 Transaction Set Purpose Use '0019' '00' 58 HEADER BHT 03 Reference 58 HEADER BHT 04 Date Date Format is CCYYMMDD 58 HEADER BHT 05 Time Time Format is HHMM 59 HEADER BHT 06 Transaction Type CH Transmission Type 60 HEADER REF 01 Reference Use '87' 58

59 60 HEADER REF 02 Transmission Type X096DA1 when submitting Test File '004010X096A1' when submitting Production File Loop ID 1000A - Submitter Name A NM1 01 Entity Identifier A NM1 02 Entity Type A NM1 03 Last Name or Organization Name Use '41' appropriate Submitters Last or Organization Name A NM1 04 Name First Required if NM102 = A NM A NM1 09 Use '46' the 9- digit ProviderOne ID. This should be same as ISA06 and GS02 Submitter EDI Contact Information A PER 01 Contact Function Use 'IC' A PER 02 Name First Submitter Contact Name 59

60 A PER 03 Communication Number A PER 04 Communication Number A PER 05 Communication Number A PER 06 Communication Number 'TE' Submitter Contact Phone Number 'EM' Submitter Contact Address Loop ID 1000B - Receiver Name B NM1 01 Entity Identifier B NM1 02 Entity Type B NM1 03 Name Last or Organization Name B NM B NM1 09 Use '40' Use '2' 'WA State DSHS' Use '46' Loop ID 2000A - Billing/Pay-To Provider Hierarchical Level A HL 01 Hierarchical ID Number A HL 03 Hierarchical Level A HL 04 Hierarchical Child Use '20' Use '1' 60

61 Billing/Pay-To Provider Specialty Information A PRV 01 Provider appropriate code If 'BI' is used than the taxonomy code will be applied to the Billing Provider in 2010AA If 'PT' is used, than the taxonomy code will be applied to the Pay-To Provider in 2010AB A PRV 02 Reference A PRV 03 Provider Taxonomy (Specialty ) Use 'ZZ' Provider Taxonomy Loop ID 2010AA - Billing Provider Name AA NM1 01 Entity Identifier AA NM1 02 Entity Type AA NM1 03 Last Name or Organization Name Use '85' appropriate code Billing Provider Last or Organization Name 61

62 AA NM1 08 code qualifier For Healthcare Providers please use 'XX' For Atypical Providers who are not required to have an NPI please use one of the following qualifiers: 24 - Employer ID 34 - SSN AA NM1 09 code Billing Provider NPI if NM108 = 'XX' Employer Number or Social Security Number of Billing Provider if NM108 = '24' or '34' Billing Provider Address AA N3 01 Address Information Address of Billing Provider AA N3 02 Address Information Billing Provider City/State/Zip AA N4 01 City Name City Name of Billing Provider AA N4 02 State or Province State of Billing Provider AA N4 03 Postal Zip of Billing Provider 62

63 Billing Provider Secondary AA REF 01 Reference 'EI' or 'SY' if NM108 = 'XX' '1D' if NM108 = '24' or '34' AA REF 02 Reference Employers Number or Social Security Number of Billing Provider if REF01 = 'EI' or 'SY' 9 digit alphanumeric ProviderOne ID if REF01 = '1D' Billing Provider Contact Information Required if this information is different than that contained in the Loop 1000A - Submitter PER Segment. If different, please use the following guidelines AA PER 01 Contact Function Use 'IC' AA PER 02 Name Billing Provider Contact Name AA PER 03 Communication Number AA PER 04 Communication Number 'TE' Billing Provider Contact Phone Number 63

64 AA PER 05 Communication Number AA PER 06 Communication Number 'EM' Billing Provider Contact Address Loop ID 2010AB - Pay-To Provider Name Required if the Pay-to Provider is a different entity than the Billing Provider. If different, please use the following guidelines. If used, please use 'PT' in Loop 2000A, Data Element PRV AB NM1 01 Entity Identifier AB NM1 02 Entity Type AB NM1 03 Last Name or Organization Name AB NM1 08 code qualifier Use '87' appropriate code Pay-To Provider Last or Organization Name For Healthcare Providers please use 'XX' For Atypical Providers who are not required to have an NPI please use one of the following qualifiers: 24 - Employer ID 34 - SSN 64

65 AB NM1 09 code Pay-To Provider NPI if NM108 = 'XX' Employer Number or Social Security Number of Pay-To Provider if NM108 = '24' or '34' Pay-To Provider Address AB N3 01 Address Information Address of Pay-To Provider AB N3 02 Address Information Pay-To Provider City/State/Zip AB N4 01 City Name City Name of Pay-To Provider AB N4 02 State or Province State of Pay-To Provider AB N4 03 Postal Zip of Pay-To Provider 65

66 Pay-To Provider Secondary AB REF 01 Reference 'EI' or 'SY' if NM108 = 'XX' '1D' if NM108 = '24' or '34' AB REF 02 Reference Employers Number or Social Security Number of Billing Provider if REF01 = 'EI' or 'SY' 9 digit alphanumeric ProviderOne ID if REF01 = '1D' Loop ID 2000B - Subscriber Hierarchical Level B HL 01 Hierarchical ID Number B HL 02 Hierarchical Parent ID Number B HL 03 Hierarchical Level B HL 04 Hierarchical Child Use '22' appropriate code 66

67 Subscriber Information B SBR 01 Payer Responsibility sequence Number B SBR 02 Individual Relationship code B SBR 09 Claim Filing Indicator appropriate Use '18' 'MC' Loop ID 2010BA - Subscriber Name BA NM1 01 Entity Identifier BA NM1 02 Entity Type BA NM1 03 Last Name or Organization Name Use 'IL' '1' Last Name of Subscriber BA NM1 04 First Name First Name of Subscriber BA NM1 08 code qualifier 'MI' BA NM1 09 code 11 digit ProviderOne Client ID ProviderOne Client ID is 9 numeric digits followed by 'WA' Example is WA 67

68 Subscriber Address BA N3 01 Address Information BA N3 02 Address Information Address of Subscriber Subscriber City/State/Zip BA N4 01 City Name City Name of Subscriber BA N4 02 State or Province State of Subscriber BA N4 03 Postal Zip of Subscriber Subscriber Demographic Information BA DMG 01 Date Time Period Format Use 'D8' BA DMG 02 DOB Subscriber Date of Birth BA DMG 03 Gender Gender of Subscriber Loop ID 2010BC - Payer Name BC NM1 01 Entity Identifier Use 'PR' BC NM1 02 Entity Type Use '2' BC NM1 03 Last Name or Organization Name 'WA State DSHS' 68

69 BC NM BC NM1 09 'PI' '77045' Payer Address BC N3 01 Address Information BC N3 02 Address Information 'Claims Processing' 'PO BOX 9248' Payer City/State/Zip BC N4 01 City Name 'Olympia' BC N4 02 State or Province 'WA' BC N4 03 Postal '98504' Loop ID Claim Information CLM 01 Claim Submitter's Identifier Patient Account Number CLM 02 Monetary Amount Total Claim Charge Amount CLM 05-1 Facility Value appropriate Type of Bill CLM 05-2 Facility Use 'A' 69

70 CLM 05-3 Claim Frequency Type appropriate UB-04 Claim Frequency Type CLM 06 Yes/No Condition or Response CLM 07 Provider Accept Assignment CLM 08 Yes/No Condition or Response CLM 09 Release of Info code CLM 18 Yes/No Condition or Response appropriate code appropriate code appropriate code appropriate code Discharge Hour the following guidelines if the Discharge Hour is necessary to adjudicate the claim DTP 01 Date Time DTP 02 Date Time Period Format Use '96' Use 'TM' DTP 03 Discharge Hour Discharge Hour Time Format in HHMM 70