Streamline SmartCare Network180 EHR

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1 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 1 of 8 Streamline SmartCare Network180 EH HIPAA 837 Companion Guide for Direct Submitters (V 1.0 Updated 08/28/2016)

2 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 2 of 8 Contents HIPAA 837 Companion Guide for Direct Submitters (V 1.0 Updated 08/28/2016)... 1 Getting Started... 2 SmartCare Specifications / equirements... 2 Table 1 Providers File Validation... 5 File Format Errors... 5 Parsing Errors... 6 Processing Errors... 6 Getting Started In order to submit a valid transaction, please refer to the National Electronic Data Interchange Transaction Set Implementation Guides & Addenda for the Health Care Claim: Institutional ASC X12N 837 (005010X223A1) and the Health Care Claim: Professional ASC X12N 837 (005010X222A1). The transaction guides can be ordered from the Washington Publishing Company s website at SmartCare Specifications / equirements In addition to the required segments and data elements in the 837 Implementation Guides, the following tables document the SmartCare specific requirements for different provider types. For Medicare Organization Providers and related subparts that are covered entities under HIPAA, the National Provider Identifier (NPI) is required for submitting 837 claims in the SmartCare system. For specific guidance, see Table 1 Providers. Generic information about the file or the content of the file: You must name your files with a.837 extension A file cannot contain more than one ST/SE segment and cannot contain more than one GS/GE segment. BHT03 cannot be repeated by a provider.

3 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 3 of 8 NPI submitted by the provider under billing provider must match at least one site assigned to the provider in Smartcare system. Provider has the option to submit claims for multiple sites as long as the billing provider segment has at least one valid NPI.. Network180 recommends that providers who submit claims for both SUD and MH/DD services utilize two NPIs. However, Network180 system will have the capability to handle both SUD and MH/DD services with one NPI. If two NPIs are utilized, SUD claims and MH/DD claims should not be submitted in the same file. Providers with questions should contact Network180 IS Helpdesk at HelpDesk@Network180.org or call

4 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 4 of 8 Table 1 Providers In the table that follows: Usage =equired, S= Situational Loop N/A Segment ID EF Segment Transmission Type 837 Segment Information Data Element ID Data Element Usage Comments EF A NM1 Submitter Name NM A NM1 Submitter Name NM B NM1 eceiver Name NM103 Transmission Type Code Name Last or Organization Name Submitter Identifier Name Last or Organization Name Network180 When submitting test records and during production, please use X222A1. Submitter Name is the 'Provider Name' from the Smartcare system and can be found in the Provider Information Banner under the element Provider Name. This can be obtained by contacting Network180 s IS Helpdesk. This will be NPI of the provider submitting the claim. All providers must provide at least one NPI to Network180 helpdesk prior to submitting claims. This NPI will be linked to submitter in Streamline system. In case of a clearing house, the NPI of the clearinghouse must be submitted. If a clearinghouse is submitting claims for more than two providers, the clearinghouse can still use one NPI. However, the file must only contain claims for one provider. In such case, billing provider will dictate which provider claims are being submitted by the clearinghouse. 1000B NM1 ecievername NM AA NM1 Billing Provider Name NM108 eceiver Identifier Code Qualifier Use Network180 NPI National Provider Identifier (NPI) is mandated for use by the HIPAA regulations. Effective May 23rd A Qualifier of XX must now be submitted. 2010AA NM1 Billing Provider Name NM BA NM1 Subscriber NM109 Subscriber Demographic 2010BA DMG Information DMG02 Billing Provider Identifier Provider must submit their 10 digit NPI Number Subscriber primary identifier is uniquely identified. The primary identifier for each client is equivalent to the "clientid" identified in the Smartcare system. Subscriber If an incorrect clientid is submitted, Smartcare Primary system will not process the claim. Provider must Identifier resubmit the claim. Subscriber Birth Date Subscriber birth date is accessible in the Smartcare system.

5 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 5 of BB NM1 Payer Name NM103 Payer Name Network BB NM1 Payer Name NM108 Code Qualifier Use: PI 2010BB NM1 Payer Name NM109 Code 2300 EF 2300 EF eference ID qualifier Prior authorization number EF01 EF02 Code Qualifier Prior authorization number S S Use Network180 NPI Providers are required to send the Site ID instead of Authorization Number, prefixed with S-. S can be lower or upper case, but upper case is preferred. Site IDs are assigned by Network180 and can be found in Allowable Services published by Network180. Site IDs are assigned for all authorizations sent by Network180. In case of a service that does not require an authorization, appropriate Site ID should be used based on Allowable Services. As an example of how to use site id in the EF*G1 segment: EF*G1*S-123. In this case, 123 is considered the Site ID. 837 File Validation SmartCare utilizes 3 levels of validation when processing 837 files 1. File Format Errors 2. Parsing Errors 3. Processing Errors File Format Errors Upon submitting an 837 file for processing, the SmartCare system runs through an exhaustive verification of the 837 file to determine if there are any formatting errors in the file. Such errors include, but are not limited to: File is not EDI X12 format Missing Header Information Missing Trailer Information In the cases in which file format validation fails, there will be no Parsing Errors and no Batches displayed. Additionally, the 997 file text will indicate that the 837 file was rejected. If the file file was successfully processed, the SmartCare will produce a 997 file stating that the file was successfully accepted.

6 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 6 of 8 Parsing Errors After successfully completing the File Format validation process, the file is then checked for any Parsing Errors. The following validations are handled in the parsing validation: Claim charge amount does not match sum of service charge amount o This error indicates that there is a discrepancy in the total charge amount submitted for all claims, and the sum of charges for service lines. Batch Submitter ID does not match selected Sender's Submitter Id o This error indicates that the Submitter ID submitted does not match the Sender Submitter ID setup in SmartCare. See the section for loop 1000A, Segment NM1, Data Element NM109 in the tables above for additional details on how to obtain Submitter ID. Batch Submitter Name does not match selected Sender's Submitter Name o This error indicates that the Submitter Name submitted does not match the Sender Submitter Name setup in SmartCare. See the section for loop 1000A, Segment NM1, Data Element NM103 in the tables above for additional details on how to obtain Submitter Name. Batch has already been imported once. o This error indicates that the Batch ID submitted in the 837 file has previously been submitted. In the cases in which parsing errors occur, processing of the file will stop and no claims will be accepted. Processing Errors If no Parsing Errors are found, the file is finally checked for any processing errors. If a file contains only processing errors, a 997 will be generated as accepted. The processing errors will be produced as a report along with other information from the weekly claims batch such as pending, rejecting and A. If a claim submitted results in a processing error in the system, Network180 will evaluate the claim and eliminate errors if information needed for processing successfully is already available somewhere else in the system. Those errors are marked below as Network180 will re-process. If Network180 could not resolve the issue, the claim will be result in a processing error and will not be considered a Clean Claim, which is described in Network180 policy. Processing errors are broken out in 2 main types: 1. Claim Errors Each error code is prefixed by the letter C 2. Claim Line Errors Each error code is prefixed by the letters CL The following is the list of processing errors which are validated: Error Code C101 C102 Claim Errors Error Description 'Unknown claim type' (Only Professional or Institutional Allowed) 'Provider/Site not found' (Tax ID / NPI does not exist in SmartCare System)

7 Last modified 8/28/2016 Network180-Streamline837CompanionGuide doc Page 7 of 8 C103 C104 C105 C106 C107 C108 C109 C110 C111 C112 C113 C114 C115 C116 C117 C118 Network180 will re-process 'Provider/Site not found in Import837SenderProviders' (A valid match exists in the system but is not setup for the Sender/Submitter) Network180 will re-process 'Client not found' (ClientId does not exist) Network180 will re-process 'Client is not active' Network180 will re-process 'Client is not authorized for this provider' (Authorization has not been released to this provider for this client) Network180 will re-process 'Insurer not found' (Loop 2010BB, Segment NM1, Data Element NM109 does not match the approved list in the tables above see NM1 ) Network180 will reprocess 'Claim rendering provider not found' (If endering Provider is specified but does not exist in the SmartCare system) Network180 will re-process 'Claim rendering provider not associated with billing provider' (endering Provider is setup in the SmartCare system but not linked to the provider ) Network180 will re-process Claim place of service not specified (Value was not specified in 837 file) Claim place of service not found (Value specified in 837 file does not match any in SmartCare system) More than one provider/site found for submitted NPI O No Authorization Found ( Network180 will re-process Provider/site not found - Network180 will re-process Principal diagnosis is invalid Other diagnosis 1 is invalid Other diagnosis 2 is invalid Other diagnosis 3 is invalid Admitting Diagnosis is invalid Error Code CL101 CL102 CL103 Error Description Claim Line Errors 'Claim line rendering provider not found' (If endering Provider is specified but does not exist in the SmartCare system) Network180 will re-process 'Claim line rendering provider not associated with billing provider' (endering Provider is setup in the SmartCare system but not linked to the provider) Network180 will re-process Claim line place of service not found (Value specified in 837 file does not match any in SmartCare system)

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