837 Dental Health Care Claim

Transcription

1 Companion Document 837D 837 Dental Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for dental claims. The remaining sections of this appendix include tables that provide information about 837 Claim segments and data elements that require specific instructions to efficiently process through BlueCross BlueShield of Georgia (BCBSGa) systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide Health Care Claim: Dental, 837, ASC X12N 837 (004010X097), May 2000, and the subsequent Addenda (004010X097A1), October 2002, published by the Washington Publishing Co. BlueCross BlueShield of Georgia Page 1 of 11

2 1 Uppercase Letters When entering alpha characters into the 837, use only UPPERCASE. As specified in the 837 IG, the basic character set includes uppercase letters, digits, space, and other special characters. For further information, see the 837 IG. 2 Delimiters When sending an ANSI ASC X12N transaction, BCBSGa uses the following delimiters to separate data elements or subelements and to terminate segments. Data Element Separator, Asterisk, (*) Sub-Element Separator, Colon, (:) Segment Terminator, Tilde (~) These delimiters are for illustration purposes only and are not specific recommendations or requirements. 3 Numeric s, Monetary Amounts and Unit Amounts BCBSGa accepts a line item charge amount equal to zero (000): SV302 Monetary Amount Line Item Charge Amount BlueCross BlueShield of Georgia Page 2 of 11

3 837 Dental Claim Header The 837 Claim Header identifies the start of a transaction, the specific transaction set, and its business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for BCBSGa processing. IG Segment Loop ID 1000A Submitter Name P.67 NM1 Submitter Name Code Loop ID 1000B Receiver Name P.74 NM1 Receiver Name NM103 Receiver Name Code 837 Dental Health Care Claim Header (Submitter Identifier) UPPERCASE BCBSGA SB601 EDI Assigned Sender ID. Identical to value in ISA06 and GS02. BCBSGA - BlueCross BlueShield of Georgia For dental claims, these values identify BCBSGa as the payer/receiver. 837 Dental Claim Detail The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant levels include: 1) Information Source (Billing/Pay-to ) 2) Subscriber (Can be the Patient when the Patient is the Subscriber) 3) Dependent (Patient when the Patient is not the Subscriber) BlueCross BlueShield of Georgia Page 3 of 11

4 1 837 Claim Detail: Billing/Pay-to Hierarchical Level The first hierarchical level (HL) of the 837 Claim Detail, Billing/Pay-to HL, identifies the original entity who submitted the electronic claim/encounter to the destination payer. IG Segment Loop ID 2010AA Billing Name P.76 NM1 Billing NM108 ID Code Code XX (Billing Primary ID) P.80 N3 Billing Address N301 Billing Address Line (Billing Street Address) P.83 REF REF01 1B Billing ID EI SY Secondary TJ REF02 (Billing Additional Identifier) Loop ID 2010AB Pay-To Name P.87 NM1 NM108 XX Pay-To ID Code P.91 N3 Pay-To Address P.94 REF Pay-To Secondary 837 Dental Health Care Claim Detail Billing/Pay-to Hierarchical Level Code (Pay-To Primary ID) N301 (Pay-To Pay-To Address Line Street Address) REF01 ID REF02 1B EI SY TJ (Billing Additional Identifier) XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers Do not enter a post office address. Enter the physical address. 1B - Blue Shield Number EI - Employer's SY - Social Security Number TJ - Tax ID 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s XX - National Identifier 24 - Employer's Number 34 - Social Security Number NPI ('XX') for Non-Exempt providers Tax ID ('24') or SSN ('34') for Exempt providers Do not enter a post office address. Enter the physical address. 1B - Blue Shield Number EI - Employer's SY - Social Security Number TJ - Tax ID 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s BlueCross BlueShield of Georgia Page 4 of 11

5 2 837 Claim Detail Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 Detail is the Subscriber HL. The following table indicates the specific values of the required Loop 2000B segments and data elements for BCBSGa processing. IG Segment Loop ID 2010BA Subscriber Name P.103 NM1 Subscriber (Subscriber Primary Name Code Identifier) 837 Dental Health Care Claim Detail Subscriber Hierarchical Level ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Member ID Format: Prefix Not required for local business Required for out-of-state (BlueExchange) claims If unsure of plan type, use prefix FEP contract numbers begin with 'R' Suffix Not required If you do include suffix, must also include matching demographic information (gender and date of birth) BlueCross BlueShield of Georgia Page 5 of 11

6 3 837 Claim Detail Patient Hierarchical Level The third hierarchical level (HL) of the 837 Claim Detail is the Patient HL. The following table indicates the specific values of the required segments and data elements for BCBSGa processing. IG Segment Loop ID 2010CA Patient Name P.136 NM1 Subscriber (Patient Primary Name Code Identifier) Loop ID 2300 Claim Information P.149 CLM CLM Claim Related Causes Information Code P.161 DTP DTP03 Date - Service Date Accident P.164 DTP DTP03 Date - Accident Date Service Loop ID 2310B Rendering Name P.195 NM1 NM108 XX Rendering ID Code P.201 REF Rendering Secondary Code REF01 ID REF Dental Health Care Claim Detail Patient Hierarchical Level (Rendering Primary ID) 1B EI SY TJ (Rendering Additional Identifier) ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. Enter the ID Number exactly as it appears on the front of the ID card, including ANY PREFIX. Prefix Not required for local business. Required for out-of-state (BlueExchange) claims. If unsure of plan type, use prefix. FEP contract numbers begin with 'R'. Suffix Not required. If you do include suffix, must also include matching demographic information (gender and date of birth). If related causes code equals 'AA' (Auto Accident) or OA (Other Accident), 2300 DTP03 (Accident Date) is required. Required if 1) 2300 HI0X-2 (Diagnosis Code) is accident-related or 2) 2300 CLM (related Causes code) equals 'AA (auto accident) or 'OA' (other accident). Electronic claims cannot span two calendar years. File charges for the previous year separately from the current year. Do not electronically file claims if service date is more than 1 year old. XX - National Identifier 24 - Employer's Number 34 - Social Security Number 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s 1B - Blue Shield Number EI - Employer's SY - Social Security Number TJ - Tax ID 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s BlueCross BlueShield of Georgia Page 6 of 11

7 IG Segment Loop ID 2400 Service Line P.265 LX LX01 Service Line Assigned Number P.266 SV3 SV301-2 Dental Procedure Code Service SV302 Line Item Charge Amount P.273 DTP Date - Service Date DTP03 Service Date Loop ID 2420A Rendering Name P.289 NM1 Rendering NM108 ID Code XX Name P.295 REF Rendering Secondary 837 Dental Health Care Claim Detail Patient Hierarchical Level Code REF01 ID REF02 See 837D IG Number of services cannot be greater than 50. See 837D IG Enter the most recent, non-expired CDT (Current Dental Terminology). See 837D IG Zero amount (000) is valid and acceptable for line charge. See 837D IG Electronic claims cannot span two calendar years. File charges for the previous year separately from the current year. Do not electronically file claims if the service date is more than one year old. (Rendering Primary ID) 1B EI SY TJ (Rendering Additional Identifier) XX - National Identifier 24 - Employer's Number 34 - Social Security Number 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s 1B - Blue Shield Number EI - Employer's SY - Social Security Number TJ - Tax ID 's EIN ('EI') or Tax ID ('TJ') 's Social Security No. ('SY') Assigned No. ('1B') - for Exempt s BlueCross BlueShield of Georgia Page 7 of 11

8 Enveloping EDI envelopes control and track communications between you and BCBSGa. One envelope may contain many transaction sets grouped into functional groups. The envelope consists of the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) BlueCross BlueShield of Georgia Page 8 of 11

9 837 Envelope Control Segments Inbound Health Care Claim Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it clearly identifies the sender, receiver, date, time, and interchange control number. BCBSGa requests that all data entered in the ISA-IEA segment be in UPPERCASE. Segment 837 Dental Health Care Claim Interchange Control Header (ISA) ISA ISA No Authorization Information Present Interchange Auth Info Control ISA02 (10 Spaces) Enter 10 positions. Header Authorization Info ISA03 Security Info No Security Information Present ISA04 Security Information ISA05 Interchange ID ISA06 Interchange Sender ID ISA07 Interchange ID ISA08 Interchange Rec ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Cntrl No. (10 Spaces) Enter 10 positions. ZZ (Submitter ID) ZZ BCBSGA (YYMMDD) (HHMM) U ISA14 Ack Requested ISA15 Usage Indicator ISA16 (X) Component Element Separator ZZ - Mutually Defined Format - Fixed length of 15 positions, alphanumeric. Left-justified followed by spaces. Identical to GS02. ZZ - Mutually Defined BCBSGA - BlueCross BlueShield of Georgia Left-justified followed by spaces. must be a valid date in YYMMDD format. must be a valid time in HHMM format. U - U.S. EDI Community of ASC X12, TDCC, and UCS Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 (Assigned by Sender) Format - Fixed length 9 positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Right-justified, filled with leading zeroes. Identical to IEA02. 0, No Acknowledgment Requested 1 - Interchange Acknowledgment Requested P, T Submitter ID must be approved to submit production data (P - Production Data; T - Test Data). X - 1 character contained in Basic or Extended Character set. must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe). BlueCross BlueShield of Georgia Page 9 of 11

10 2 837 Health Care Claim Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. BCBSGa requests that all dat in the GS-GE segment be entered in UPPERCASE. Segment 837 Dental Health Care Claim Functional Group Header (GS) GS Functional Group Header GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number HC HC - Health Care Claim (837) (Submitter ID) BCBSGA (CCYYMMDD) (HHMM) (Assigned by Sender) GS07 X Responsible Agency Code GS08 Version / Release / X097A1 Industry Identifier Code Format positions, alphanumeric. Left-justified with no trailing zeroes or spaces. Identical to ISA06. Routing of batched transactions to: BCBSGA - BlueCross BlueShield of Georgia must be a valid date in CCYYMMDD format. must be a valid time in HHMM format. Format positions, numeric. Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. Left-justified with no trailing zeroes or spaces. Identical to GE02. X - Accredited Standards Committee X12 Operationally used to identify the transaction: X097A1-837 Dental Claim NOTE. Critical Batching and Editing Information. **Transactions must be batched in separate functional group by Application Receiver s Code (GS03). ***Group Control Number (GS06) may not be duplicated by submitter. Files containing duplicate or previously received group control numbers will be rejected. BlueCross BlueShield of Georgia Page 10 of 11

11 3 837 Health Care Claim Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Segment 837 Dental Health Care Claim Functional Group Trailer (GE) GE Functional Group Trailer GE01 Number of Transaction Sets Included GE02 Group Control Number (Total Number of Transaction Sets in Functional Group or Transmission) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format positions, numeric. Left-justified with no trailing zeroes or spaces. Identical to GS Health Care Claim Interchange Control Trailer (IEA) The IEA segment is the ending, outmost level of the interchange control structure. It indicates and verifies the number of functional groups included with the interchange and the interchange control number (the same number indicated in the ISA segment). Segment 837 Dental Health Care Claim Interchange Control Trailer (IEA) IEA Interchange Control Trailer IEA01 Number of Included Functional Groups IEA02 Interchange Control Number (Number of Functional Groups GS/GE Pairs in Interchange) (Control Number) Format positions, numeric. Left-justified with no trailing zeroes or spaces. Format - Fixed length 9 positions, numeric. Unique value greater than zero. Identical to ISA13. BlueCross BlueShield of Georgia Page 11 of 11