837 Health Care Claim Professional, Institutional & Dental Companion Guide

Transcription

1 837 Health Care Claim Professional, Institutional & Dental Companion Guide X222A1 & X223A1 V. 1.2 Created 07/18/14

2 Disclaimer Blue Cross of Idaho created this companion guide for 837 healthcare claims (professional, institutional, and dental) to use with the latest A1 ANSI guide. This document is not a replacement for the ANSI X12 implementation guide. It s an additional information source created to assist providers and business partners of Blue Cross of Idaho. You can download the latest ANSI X12 implementation guide for free at: wpc-edi.com/content/view/533/377/ 2

3 Table of Contents Disclaimer 2 Intended Use 4 Enrollment & Support Information 5 General Business Information Claim Segments & Business Requirements Health Care Claim: Professional/Institutional/Dental 10 Blue Cross of Idaho Business Rules 11 3

4 Intended Use The purpose of this companion guide is to describe those aspects of processing electronic 837 Health Care Claims that are specific to Blue Cross of Idaho. As mentioned above, this companion guide is not meant to be used as a replacement for the 5010 Errata ANSI X12 Implementation Guide. This companion guide contains data clarifications derived from specific business rules that apply exclusively to claims processed by Blue Cross of Idaho. In addition, this guide includes useful information about sending and receiving data to and from Blue Cross of Idaho. Be advised Blue Cross of Idaho will update this document on a continual basis, and make the most current version available on our website, bcidaho.com. 4

5 Enrollment & Support Information Any entity desiring to send or receive electronic transactions to Blue Cross of Idaho must first be registered, and Blue Cross of Idaho will accept one enrollment form for multiple transactions. If you are interested in registering with Blue Cross of Idaho, simply complete a copy of the Electronic Claims Submission Enrollment Form at Select Electronic Claims Submission Enrollment Form under the Providers column, complete the form and Fax it to The link to the Vendor Submission Enrollment Form is under the Vendors column. After Blue Cross of Idaho has received and processed your Electronic Claims Submission Enrollment Form, there are a number of tasks that must be completed: Blue Cross will provide your login and password information Provider Submits test files, assisted by a member of the Blue Cross of Idaho EDI support desk Blue Cross will grant approval to submit production data files EDI Support The Blue Cross of Idaho EDI support desk assists users with questions about electronic transactions. The Blue Cross of Idaho EDI Support Desk is available to all providers Monday through Friday from 8 a.m. to 5 p.m. MST at or select option 2 or say support. The Blue Cross of Idaho EDI Support Desk: Provides information on services offered Enrolls users for claims submission and data retrieval Verifies receipt of electronic transmissions Provides technical assistance to users who are experiencing transmission difficulties 5

6 General Business Information Blue Cross of Idaho will only accept transactions from trading partners who completed the enrollment process, which means the entity s submitter ID is on file. We will reject all other transactions. Blue Cross of Idaho complies with the standards adopted by HIPAA. Specific coding requirements utilized by Blue Cross of Idaho are described below. Please remember that eligibility information returned by Blue Cross of Idaho is not a guarantee of claims payment. Blue Cross of Idaho will respond to all eligibility requests with the coverage information available for the patient identified per the date provided. 6

7 837 Claim Segments & Business Requirements Blue Cross of Idaho complies with the standards adopted by HIPAA when processing an 837 Professional Health Care Claim. ISA Interchange Control Header (Fixed Length) ISA01 Authorization Qualifier 00 ISA02 Authorization Information Should contain spaces ISA03 Security Qualifier 00 ISA04 Security Information Should contain spaces ISA05 Qualifier ZZ Blue Cross required ISA06 Submitter Information To be assigned (usually providers tax id) ISA07 Qualifier 30 Blue Cross required ISA08 Receiver ID Blue Cross Receiver ISA09 Interchange Date Interchange Date YYMMDD ISA10 Interchange Time Interchange Time HHMM ISA11 { Left Curly Bracket ISA12 Version ISA13 Interchange Control Number ISA14 0, 1 Not supported at this time ISA15 Indicator T, P T=Test, P=Prod GS Functional Group Header GS Element Name M Must match ISA08 BHT Beginning of Hierarchical Transaction BHT Reference identification O Used to verify the file is not a duplicate BHT Date O Cannot be a future date or older than 90 days BHT Time O 7

8 NM1 Submitter Loop 1000A NM Element Name Y 41 Qualifier NM Type Qualifier Y 1=Person, 2=Non Non person Entity NM Last or Organization Name O Person Provider Name if non person entity, First and last name if a person NM Code Qualifier C 46 NM Identification Code Providers Submitter Number NM1 Receiver Name Loop 1000B NM Element Name Y 40 Qualifier NM Type Qualifier Y 2 NM Last or Organization O Blue Cross of Idaho Name NM Code Qualifier C 46 NM Identification Code NM1 Billing Provider Identification Loop 2010AA NM101 Element Name M 85 Identifier for Billing Provider Must be registered with BCI as a valid EDI billing entity. Nm102 Type of Entity M 1, 2 1=Person 2=Non person Entity NM103 Last or Organization M Name Name NM104 First Nam M Required if NM102 is a 1 NM105 Middle Initial O Allowed if NM102 is a 1 NM108 Qualifier M XX NM109 Identification Code M Organizational NPI 8

9 REF Billing Provider Secondary Identification Loop 2010AA REF Reference Identification Qualifier M EI=Employer number REF Reference Identification C Employer Identification Number NM1 Payer Name Loop 2010AB NM Entity Identifier Code M NM Qualifier M NM Last Name or O Organizational Name NM First Name NM Middle Name NM Name Suffix NM Identification Code PI PI=Payer Id Qualifier NM Identification Code Payer Code NM1 Rendering Provider Name Claim level in the 2310C Loop Line level in the 2420A Loop NM Entity Identifier Code M 82 82=Rendering provider NM Entity Type Qualifier M 1 Must be an individual Provider NM Last or Organizational Name NM First Name NM Middle Name NM Name Suffix NM Identification Code Qualifier O If individual then enter Last name here NM Identification code O NPI of Rendering provider O XX 9

10 837 Health Care Claim: Professional/Institutional/Dental The incoming 837 transactions should utilize recommended delimiters from the following list of characters: > (Greater Than) * (Asterisk) ~ (Tilde) ^ (Carrot Top) (Vertical Bar) Data may be streaming (no <CR><LF>) or <CR><LF> delimited. Note the total length of segment separator should not exceed 3 Characters BCI recommends using only ~ for the Segment Separator. POS ID Segment Name Req Max Use Repeat Notes Page ISA Interchange Control Header M 1 9 GS Functional Group Header M 1 11 Blue Cross of Idaho Business Rules The REF G5 is not applicable to the 835. Blue Cross of Idaho processes confirmation reporting based on the ISA/GS/2010AA.NM1.09/2010AA.REF (G5).02. Reports are grouped, routed and returned by the unique combination of the values provided in the aforementioned data elements. The 2010AA REF, with a qualifier of G5, is an optional segment used by the Blue Cross of Idaho EDI services for report routing, grouping and delivery. If a Trading Partner (TP) wants to submit the same value of 2010AA.NM1.09 (billing provider NPI) for multiple locations, and not have reports grouped and routed to a single location, the TP must do one of the following: Provide the optional 2010AA.REF, mentioned above, with a value assigned by Blue Cross of Idaho. Have the Blue Cross of Idaho EDI services enroll a TP with a second GS agreement for the second occurrence of the 2010AA.NM1.09 to be submitted under. For further clarification on this policy please speak to a Blue Cross of Idaho EDI support representative. 10