Horizon Blue Cross and Blue Shield of New Jersey

Transcription

1 Horizon Blue Cross and Blue Shield of New Jersey Companion Guide for Transaction and Communications/Connectivity Information Instructions related to Transactions based on ASC X12 Implementation Guides, version Companion Guide Version Number: [10.0] Errata Version [January 2019 Maintenance] This is a working document. Changes to the information provided here may be subject to future changes/updates. Blue Cross and Blue Shield Association January

2 Preface Companion Guides (CG) may contain two types of data, instructions for electronic communications with the publishing entity (Communications/Connectivity Instructions) and supplemental information for creating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG (Transaction Instructions). Either the Communications/Connectivity component or the Transaction Instruction component must be included in every CG. The components may be published as separate documents or as a single document. The Communications/Connectivity component is included in the CG when the publishing entity wants to convey the information needed to commence and maintain communication exchange. The Transaction Instruction component is included in the CG when the publishing entity wants to clarify the IG instructions for submission of specific electronic transactions. The Transaction Instruction component content is limited by ASCX12 s copyrights and Fair Use statement. If you have any questions, please contact the Horizon BCBSNJ EDI Service Desk toll-free at or via at <HorizonEDI@HorizonBlue.com>. Representatives are available weekdays from 7 a.m. to 6 p.m. Blue Cross and Blue Shield Association January

3 Table of Contents Transaction Instruction (TI) TI Introduction Background Overview of HIPAA Legislation Compliance according to HIPAA Compliance according to ASC X Intended Use Understanding ANSI Standards for Electronic Data Interchange Transactions, Groups and Interchanges Transactions, Groups and Interchanges continued Interchange Envelopes Segment Hierarchy EDI Documentation ASC X12 Releases Included ASC X12 Implementation Guides Horizon BCBSNJ Specific Business Rules and Guidelines X222 Health Care Claim: 837 Professional Business Rules and Guidelines X223A2 Health Care Claim: 837 Institutional Business Rules and Guidelines X224A2 Health Care Claim: 837 Dental Business Rules and Guidelines X214 Health Care: 277 Claim Acknowledgment Business Rules and Guidelines X221A1 Health Care: 835 Payment/Advice Business Rules and Guidelines X220A1 Health Care: 834 Benefit Enrollment and Maintenance Business Rules and Guidelines X217 Health Care: 278 Request for Authorization (Request) Business Rules and Guidelines Acknowledgement Request to UM Review Specific Rules and Guidelines: X217 Health Care: 278 Request for Authorization (Response) Business Rules and Guidelines X279A1 Health Care: 270 Eligibility Inquiry Request Business Rules and Guidelines X279A1 Health Care: 271 Eligibility Inquiry Response Business Rules and Guidelines Blue Cross and Blue Shield Association January

4 X212 Health Care: 276 Claim Status Request Business Rules and Guidelines X212 Health Care: 277 Claim Status Response Business Rules and Guidelines X2A1 Health Care: 999 Acknowledgement Business Rules and Guidelines X218 Health Care: 820 Premium Payment Business Rules and Guidelines Transaction Testing Information Business Scenarios Professional, Institutional, and Dental Business Scenarios /271 Eligibility Inquiry And Response Business Scenarios Health Care Services Request Authorization Business Scenarios Health Care Claim Payment/Remittance Advice Business Scenarios Details - TBD Health Plan Enrollment Business Scenarios /277 Health Care Claim Status Request And Response Business Scenarios Scheduled Maintenance Frequently Asked Questions - TBD Other Resources Communications/Connectivity Information (CCI) CCI Introduction Trading Partner Registration Trading Partner Testing and Certification Approval Procedures for IS Vendors and Integrators IS Vendor and Integrator Approval Tasks: Provider Approval Tasks: Health Care Direct Submitters Approval Tasks Communication Protocols/Network Communications Communication Protocols/Network Communications Frequently Asked Questions (FAQs) Instructions for Secure FTP New Submitters Horizon BCBSNJ EDI Services EDI Service Desk Contact Information Horizon BCBSNJ EDI Transaction System Availability Routine Maintenance Non Routine Maintenance Blue Cross and Blue Shield Association January

5 13.3 Unscheduled Maintenance Emergency Control Segments / Envelopes ISA-IEA IEA Segment - Interchange Control Trailer GS-GE GS Segment - Functional Group Header GE Segment - Functional Group Trailer segment ST-SE Acknowledgements and Reports CCI Change Summary CCI Additional Information Trading Partner Agreement Frequently Asked Questions (FAQs) Other Resources..74 Blue Cross and Blue Shield Association January

6 Transaction Instruction (TI) 1. TI Introduction 1.1 Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carry provisions for administrative simplification. This requires the Secretary of the Department of Health and Human Services (HHS) to adopt standards to support the electronic exchange of administrative and financial health care transactions primarily between health care providers and plans. HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA The HIPAA regulations at 45 CFR require that covered entities not enter into a trading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in a standard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked not used in the standard s implementation specifications or are not in the standard s implementation specification(s). Change the meaning or intent of the standard s implementation specification(s) Compliance according to ASC X12 ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in the implementation guide. Modifying any requirement contained in the implementation guide. Blue Cross and Blue Shield Association January

7 1.2 Intended Use The Transaction Instruction component of this companion guide must be used in conjunction with an associated ASC X12 Implementation Guide. The instructions in this companion guide are not intended to be standalone requirements documents. This companion guide conforms to all the requirements of any associated ASC X12 Implementation Guides and is in conformance with ASC X12 s Fair Use and Copyright statements. 1.3 Understanding ANSI Standards for Electronic Data Interchange Transactions, Groups and Interchanges A transaction set is simply the term used by ANSI to describe the transmission of a single electronic document between one company's computer and another company's computer. The data included in a transaction set will usually convey the same information as a conventional printed document. Since information is being exchanged between computer applications, it is sometimes unnecessary to include all of the same details as a paper document that is intended for a person to read. For example, a health care provider s Identification Number and name may be all that is necessary when submitting a transaction through EDI since the insurance company database already contains related provider information such as address, city, state, and zip code for that provider. It may not be necessary to transmit certain information. In ANSI X12, each printed line on a document is roughly equivalent to a segment in a transaction. Each data segment has a unique 2- or 3- character identifier. Each piece of information on a printed line is roughly equivalent to a data element on a segment. Data elements are identified by their positions within a segment. Important Note: For this example the asterisk (*) and the tilde (~) are used for illustration purposes. The actual X12 transmission will use different characters as defined in the control structure section of this document. In this example, name information is converted to EDI format. Blue Cross and Blue Shield Association January

8 Entity ID Ent. Qual Last Name First Name M.I. Prefix Suffix ID Qual. ID Code IL 1 JENSEN MARY N These items become an EDI segment using six of the nine possible data elements, grouped in a specific sequence as follows: NM1*IL*1*JENSEN*MARY****N*12345~ In this example "NM1" is the segment identifier. This segment describes a person who is a subscriber, named Mary Jensen, whose Identification Number is In the Data Dictionary, "IL" is the Entity ID Code for subscriber, "1" is the Entity Code for person, "JENSEN" is the last name, "MARY" is the first name, "N" is the code qualifier for the insured unique ID, and "12345" is the actual ID number. Using Delimiters A data element delimiter (asterisk) separates each of the elements. A segment terminator (~) ends each segment. Adjacent delimiters (** or ***) indicate that optional data elements are omitted. In this example the values for middle initial, prefix and suffix are not used therefore we have adjacent delimiters in the segment NM1*IL*1*JENSEN*MARY****N*12345~ Blue Cross and Blue Shield Association January

9 A segment terminator may be placed after the last data element present if optional data elements are omitted. In this case there are potentially 9 data elements on the "NM1" segment as defined in the segment directory. We have used 6 of the 9. The segment terminator character is placed after the "12345" value. If there were more optional elements defined on this segment that were not used, the terminator would still be placed after the last element present, rather than have unnecessary asterisks finishing the segment. This concept is illustrated below using a different segment: Incorrect: SBR*P*********~ (Extra delimiters unnecessary.) Correct: SBR*P~ (Terminator placed after last element used.) Segments are built by grouping data elements as defined by the X12 standards. Transaction sets are built by grouping segments as defined by the X12 standards. Multiple transaction sets of the same type may be combined and transmitted together in functional groups. Multiple functional groups may be combined and transmitted in EDI interchanges. 1.4 Interchange Envelopes All EDI communications transmitted between Trading Partners will be grouped into envelopes. The beginning of each EDI document is identified using a transaction set header segment (ST). The end of every document is marked using a transaction set trailer segment (SE). EDI documents of a similar nature and destined for one Trading Partner are gathered into a functional group, identified by a functional group header segment (GS) and a functional group trailer segment (GE). Each GS segment marks the beginning of a functional group. There can be many functional groups within an interchange envelope. EDI documents transmitted during a session are identified by an interchange header segment (ISA) and trailer segment (IEA). Each ISA marks the beginning of the transmission and provides sender and receiver identification. Blue Cross and Blue Shield Association January

10 1.5 Segment Hierarchy ISA - Interchange Control Header segment GS - Functional Group Header segment ST - Transaction Set Header segment Transaction Set in available Specifications SE - Transaction Set Trailer segment GE - Functional Group Trailer segment IEA - Interchange Control Trailer segment 2. EDI Documentation 2.1 ASC X12 Releases Since 1986, by approval of ANSI, the ASC X12 Secretariat has published a series of releases. These documents represent X12-approved revisions of those previously published American National Standards. As such, releases are not American National Standards, since their contents have not been subjected to the rigors of the public review process required by ANSI for such considerations. In the form provided in releases, all of the standards are considered to be Draft Standards for Trial Use (DSTU's). ASC X12's purpose in publishing these releases is to put current ASC X12 approved draft standards into the hands of users in a more frequent basis. The ANSI standards process is lengthy. Blue Cross and Blue Shield Association January

11 The Data Interchange Standards Association (DISA) monitors the progress and oversees the publication of the draft standards. DISA can be contacted at the following address: It is recommended that you purchase the following document: ASC X12 standards are obtained from: Website: Phone: (425) FAX: (775) Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply. Unique ID Name [005010X222A1 Health Care Claim: Professional (837)] [005010X223A2 Health Care Claim: Institutional (837)] [005010X224A2 Health Care Claim: Dental (837)] [005010X214 Health Care Claim Acknowledgment (277CA)] [005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271)] [005010X221A1 Health Care Claim Payment/ Advice (835)] [005010X212 Health Care Claim Status Request and Response (276/277)] [005010X217 Health Care Services Review-Request for Review and Response (278)] [005010X220A1 Benefit Enrollment and Maintenance (834)] [005010X218 Payroll Deducted and Other Group Premium Payment for Insurance Products (820)] [005010X231A1 Implementation Acknowledgment 999}] Blue Cross and Blue Shield Association January

12 4. Horizon BCBSNJ Specific Business Rules and Guidelines X222A1 Health Care Claim: 837 Professional Business Rules and Guidelines 1. When an NPI is obtained from CMS, it must be communicated to Horizon BCBSNJ so that it can be loaded to internal processing tables. This will allow for adequate processing of your transaction 2. All characters sent must be upper case. 3. All batch numbers (BHT03) should be unique. 4. All Patient Control numbers should be unique. 5. An Acknowledgement Response 277CA will be available the next business day. If you do not receive the Acknowledgement response timely or if it does not represent all the transactions submitted, contact Horizon BCBSNJ EDI at or the EDI Service Desk at The Acknowledgement transaction will provide status on the previous claims transmitted to Horizon BCBSNJ and pass Horizon s compliance checking process. 6. A 999 will be utilized to indicate functional acknowledgement when a file/transaction is rejected for non-compliance. When a 999 is returned for noncompliance, an error status will indicate the error location, allowing submitter to correct and re-submit the file. 7. Rejected claims contained in the Acknowledgement transaction will not be forwarded to Horizon BCBSNJ Claims Processing Systems. A batch containing rejected claims will forward only the accepted claims to the Horizon BCBSNJ Processing Systems. Submitter must correct rejected claim and resubmit for consideration. 8. Please submit your claims in one ST.SE per claim, this will prevent the rejection of an entire batch of claims if only one claim is not in compliance. When the 999 is returned for non-compliance, an error status will indicate the error location, allowing the submitter to correct and resubmit the entire file. 9. Submit the Horizon BCBSNJ Subscriber ID number as indicated on the insurance card. 10. Horizon BCBSNJ does not handle Payer to Payer COB. Payer to Payer COB is defined as the electronic transmission of the Horizon BCBSNJ finalized claim to a secondary payer for their consideration or vice versa. 11. Horizon BCBSNJ will process secondary COB claims received from a provider. These claims are defined as a primary carrier has processed the claim, and it is being submitted to Horizon BCBSNJ for secondary consideration. 12. All claims submitted to Horizon BCBSNJ for secondary/tertiary consideration should only be submitted after the previous payer(s) have processed the claim. 13. Submission of Pay-To Provider information does not guarantee that payment Blue Cross and Blue Shield Association January

13 will be made to that provider. Horizon BCBSNJ will make any payments based on contractual agreements previously established. 14. Horizon BCBSNJ supports fast batch submission for primary claims only. 15. Horizon BCBSNJ strongly suggests that the Patient Responsibility and Contractual Obligation information be submitted on secondary/tertiary claims, when appropriate. Loop Id Reference Implementation Name Codes Notes/Comments 1000A NM109 Submitter Identifier Submitter Tax ID 1-9 must be numeric. 1000B NM103 Receiver Name Must be "HORIZON BCBSNJ" 1000B NM109 Receiver Primary Identifier Must be "22099". 2000A CUR Foreign Currency Information 2010AA NM1 Billing Provider Name Horizon BCBSNJ accepts claim submitted in US dollars only. For Horizon BCBSNJ business, if the billing provider is a group (NM102=2), individual Rendering Provider information is required at Loop 2310B and/or Loop 2420A. 2010AA N302 Billing Provider Address Line Example: Floor, Apartment number, etc. 2010AA 2010AA 2010AA N403 REF01 REF Billing Provider Postal Zone or ZIP Code CODE SOURCE: 51: ZIP Code 932: Universal Postal Codes When reporting the ZIP code for U.S. addresses, the full nine digit ZIP code must be provided. Must contain a valid 9-digit zip code for Horizon BCBSNJ business. Reference Identification EI Must be used for Horizon BCBSNJ business. For Horizon BCBSNJ business, the Billing Provider's 9 digit Tax ID is required in the REF02, qualified by a value of 'EI' in the Billing Provider Tax REF01. If not submitted this way, the claim Identification will reject. Blue Cross and Blue Shield Association January

14 Loop Id Reference Implementation Name Codes Notes/Comments 2010AB 2010AC 2000B N403 NM108 SBR09 Pay-to Address Postal Zone or ZIP Code CODE SOURCE: 51: ZIP Code 932: Universal Postal Codes Must contain a valid zip code for Horizon BCBSNJ business. Identification Code PI Used for Horizon BCBSNJ business Claim Filing Indicator Code BL Horizon BCBSNJ strongly recommends using this code for Horizon BCBSNJ Claims. 2010BA NM102 Entity Type 1 Required for Horizon BCBSNJ business. 2010BA NM104 Subscriber First Name Required for Horizon BCBSNJ business Identification Code 2010BA NM108 MI Must be used for Horizon BCBSNJ business 2010BA 2010BA 2010BA NM109 REF PER Subscriber Primary Identifier Property and Casualty Claim Number Property and Casualty Subscriber Contact Information Must contain the Horizon BCBSNJ Subscriber ID Number as indicated on the insurance card. Horizon BCBSNJ will reject claims received with property and casualty claim information. Horizon BCBSNJ will reject claims received with property and casualty claim information. 2010BB NM103 Payer Name Must be "HORIZON BCBSNJ". Identification Code 2010BB NM108 PI Must be used for Horizon BCBSNJ business. 2010BB NM109 Payer Identifier Must be "22099". 2010BB N3 Payer Address Not needed for Horizon BCBSNJ business. 2010BB 2010BB 2010BB N4 REF REF01 Payer City, State, ZIP Code Payer Secondary Identification Reference Identification G2 Not needed for Horizon BCBSNJ business. Not needed for Horizon BCBSNJ business. This is no longer a required field, however, Horizon BCBSNJ will not reject the Legacy ID# (9-digit Tax ID# + Alpha suffix), if sent in on a claim. 2010CA REF 2300 DTP 2300 PWK Property & Casualty Patient Identifier Property and Casualty Date of First Contact Claim Supplemental Information Horizon BCBSNJ will reject claims received with property and casualty claim information. Horizon BCBSNJ will reject claims received with property and casualty claim information. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. Blue Cross and Blue Shield Association January

15 Loop Id Reference Implementation Name Codes Notes/Comments 2300 CN1 Contract Information Not used for Horizon BCBSNJ business REF02 Referral Number Reference Identification Reference Identification 2300 REF REF 2300 CR CRC 2300 HI 2310A 2310A NM108 NM109 Prior Authorization Reference Identification Payer Claim Control Number Ambulance Transport Information Ambulance Certification Health Care Diagnosis Code Identification Code Referring Provider Identifier Must contain Horizon BCBSNJ Prior Authorization number. For Horizon BCBSNJ business, the original ICN # must be submitted for adjustment claims, if not present will be rejected. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. For Horizon BCBSNJ business the principal diagnosis code is required and cannot have a V, W, X, or Y in the first position of the code. Claims received without a principal diagnosis code or with a V, W, X, or Y " in the first position of the code will be rejected. For Horizon BCBSNJ business, a Provider ID is required for the Referring Provider. Must contain the Referring provider's NPI number 2310B NM1 Rendering Provider Name For Horizon BCBSNJ business, if the billing /pay-to provider is a group (Loop 2010AA/2010AB, NM102=2), individual Rendering Provider information is required. 2310B REF 2320 CAS A NM B DTP 2330B REF Rendering Provider Secondary Identification Claim Adjustment Group Code CO This is not a required field, however, Horizon BCBSNJ will not reject the Legacy ID# (9-digit Tax ID# + Alpha suffix), if sent in on a claim Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. Identification Code MI Must be used for Horizon BCBSNJ business Horizon BCBSNJ business requires that Medicare primary claims submitted for secondary consideration must contain the Claim Check or Claim Adjudication Date in this segment. If not Remittance Date submitted, the claim will be rejected. Other Payer Claim Control Number Horizon BCBSNJ requests that Medicare primary claims submitted for secondary consideration contain the Medicare original Blue Cross and Blue Shield Association January

16 Loop Id Reference Implementation Name Codes Notes/Comments ICN in REF02 of this segment SV SV SV SV PWK 2400 PWK 2400 CR CRC Product/Service ID Product/Service ID Product/Service ID Product/Service ID Line Supplemental Information Durable Medical Equipment Certificate of Medical Necessity Indicator Ambulance Transport Information Ambulance Certification ER HC IV WK Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. Must be used for Horizon BCBSNJ business. Include the submission of J codes here. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected CN1 Contract Information Not used for Horizon BCBSNJ business REF02 Prior Authorization Number Reference Identification Must contain Horizon BCBSNJ Prior Authorization number AMT Sales Tax Amount For Horizon BCBSNJ business sales tax should be bundled with total charges. All claims submitted with separate sales tax segments will be rejected HCP HCP HCP HCP A NM1 Product/Service ID Product/Service ID Product/Service ID Product/Service ID Rendering Provider Name ER HC IV WK Must NOT be used for Horizon BCBSNJ business, will be rejected if sent Must be used for Horizon BCBSNJ business. Include the submission of J codes here. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent Required for Horizon BCBSNJ business, if the billing/pay-to provider is a group (Loop 2010AA/2010AB, NM102=2) Blue Cross and Blue Shield Association January

17 Loop Id Reference Implementation Name Codes Notes/Comments 2420A REF01 Reference Identification G2 2420A REF02 Rendering Provider Secondary Identification This is no longer a required field, however, Horizon BCBSNJ will not reject the Legacy ID# (9-digit Tax ID# + Alpha suffix), if sent in on a claim. 2420E REF01 Reference Identification G2 2420F 2420F NM108 NM109 Identification Code Referring Provider Identifier For Horizon BCBSNJ business, a Provider ID is required for the Referring Provider. Must contain the Referring Provider's NPI# 2430 SVD03-01 Product/Service ID ER Must NOT be used for Horizon BCBSNJ business, will be rejected if sent 2430 SVD SVD03-01 Product/Service ID Product/Service ID HC IV Must be used for Horizon BCBSNJ business. Include the submission of J codes here. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent 2430 SVD CAS CAS01 Product/Service ID Claim Adjustment Group Code Claim Adjustment Group Code WK CO PR Must NOT be used for Horizon BCBSNJ business, will be rejected if sent Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. (I.e. Medicare Allowed Amount) Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. (I.e. Medicare Allowed Amount) 2430 CAS03 Adjustment Amount When the submitted charges are paid in full, the value of CAS03 should be zero. 2010CA NM104 Patient First Name Must be used for Horizon BCBSNJ business 2010CA 2010CA REF PER Property and Casualty Claim Number Property and Casualty Patient Contact Information 2300 CLM Claim Information 2300 DTP Property and Casualty Date of First Contact Horizon BCBSNJ will reject claims received with property and casualty claim information. Horizon BCBSNJ will reject claims received with property and casualty claim information. Clarification Note: This segment must be sent when the Dependent is the patient. Horizon BCBSNJ will reject claims received with property and casualty claim information. Blue Cross and Blue Shield Association January

18 Loop Id Reference Implementation Name 2300 PWK Claim Supplemental Information Codes Notes/Comments At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted CN1 Contract Information Not used for Horizon BCBSNJ business REF02 Referral Number Reference Identification Must contain Horizon BCBSNJ Referral number REF REF Prior Authorization Reference Identification Payer Claim Control Number Must contain a Horizon BCBSNJ Prior Authorization number For Horizon BCBSNJ business, the original ICN # must be submitted for adjustment claims, if not present will be rejected CR CRC 2300 HI Ambulance Transport Information Ambulance Certification Health Care Diagnosis Code This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. For Horizon BCBSNJ business the principal diagnosis code is required and cannot have a V, W, X, or Y in the first position of the code. Claims received without a principal diagnosis code or with a V, W, X, or Y " in the first position of the code will be rejected. 2310A 2310A NM108 NM109 Identification Code Referring Provider Identifier For Horizon BCBSNJ business, a Provider ID is required for the Referring Provider. Must contain the Referring Provider's NPI# 2310B REF 2320 CAS CAS A NM108 Rendering Provider Secondary Identification Claim Adjustment Group Code Claim Adjustment Group Code CO PR Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. Identification Code MI Must be used for Horizon BCBSNJ business Blue Cross and Blue Shield Association January

19 Loop Id Reference Implementation Name 2330B 2330B DTP REF 2400 SV SV SV SV PWK 2400 PWK 2400 CR CRC Claim Check or Remittance Date Other Payer Claim Control Number Product/Service ID Product/Service ID Product/Service ID Product/Service ID Line Supplemental Information Durable Medical Equipment Certificate of Medical Necessity Indicator Ambulance Transport Information Ambulance Certification Codes ER HC IV WK Notes/Comments Horizon BCBSNJ business requires that Medicare primary claims submitted for secondary consideration must contain the Claim Adjudication Date in this segment. If not submitted, the claim will be rejected. Horizon BCBSNJ business requires that Medicare primary claims submitted for secondary consideration must contain the Medicare original ICN in REF02, qualified by the "F8" qualifier in REF01. Claims not submitted with this information will be rejected. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. Must be used for Horizon BCBSNJ business. Include the submission of J codes here. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected. This segment is required for Horizon BCBSNJ business when a procedure code of A0021- A0999 is used, if not sent will be rejected CN1 Contract Information Not used for Horizon BCBSNJ business REF02 Prior Authorization or Referral Number 2400 AMT Sales Tax Amount 2400 HCP HCP09 Product/Service ID Product/Service ID ER HC Must contain Horizon BCBSNJ Prior Authorization number. For Horizon BCBSNJ business sales tax should be bundled with total charges. All claims submitted with separate sales tax segments will be rejected. Must NOT be used for Horizon BCBSNJ business, will be rejected if sent Must be used for Horizon BCBSNJ business. Include the submission of J codes here. Blue Cross and Blue Shield Association January

20 Loop Id Reference Implementation Name Codes Notes/Comments 2400 HCP09 Product/Service ID IV Must NOT be used for Horizon BCBSNJ business, will be rejected if sent HCP09 Product/Service ID WK Must NOT be used for Horizon BCBSNJ business, will be rejected if sent 2420A NM1 Rendering Provider Name For Horizon BCBSNJ business if the billing/pay-to provider is a group (Loop 2010AA/2010AB, NM102=2),individual Rendering Provider information is required. 2420A REF01 Reference Identification G2 2420A REF02 Rendering Provider Secondary Identification This is no longer a required field, however, Horizon BCBSNJ will not reject the Legacy ID# (9-digit Tax ID# + Alpha suffix), if sent in on a claim. 2420E REF01 Reference Identification G2 2420F 2420F NM108 NM109 Identification Code Referring Provider Identifier For Horizon BCBSNJ business, a Provider ID is required for the Referring Provider. Must contain the Referring Provider's NPI# 2430 SVD03-01 Product/Service ID ER Must NOT be used for Horizon BCBSNJ business, will be rejected if sent 2430 SVD03-01 Product/Service ID HC Must be used for Horizon BCBSNJ business. Include the submission of codes here SVD03-01 Product/Service ID IV Must NOT be used for Horizon BCBSNJ business, will be rejected if sent 2430 SVD CAS CAS01 Product/Service ID Claim Adjustment Group Code Claim Adjustment Group Code WK CO PR Must NOT be used for Horizon BCBSNJ business, will be rejected if sent Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. (I.e. Medicare Allowed Amount) Horizon BCBSNJ strongly recommends sending this information to adjudicate the claim appropriately. (I.e. Medicare Allowed Amount) Blue Cross and Blue Shield Association January

21 X223A2 Health Care Claim: 837 Institutional Business Rules and Guidelines 1. When an NPI is obtained from CMS, it must be communicated to Horizon BCBSNJ so that it can be loaded to internal processing tables. This will allow for adequate processing of your transaction 2. All characters sent must be upper case. 3. All batch numbers (BHT03) should be unique. 4. All Patient Control numbers should be unique. 5. An Acknowledgement Response 277CA will be available the next business day. If you do not receive the Acknowledgement response timely or if it does not represent all the transactions submitted, contact Horizon BCBSNJ EDI at or the EDI Service Desk at The Acknowledgement transaction will give status on the previous claims transmitted to Horizon BCBSNJ and pass Horizon s compliance checking process. 6. A 999 will be utilized to indicate functional acknowledgement when a file/transaction is rejected for non-compliance. When a 999 is returned for noncompliance, an error status will appear to indicate the error location, allowing submitter to correct and re-submit the file. 7. Rejected claims contained in the Acknowledgement transaction will not be forwarded to Horizon BCBSNJ Claims Processing Systems. A batch containing rejected claims will forward only the accepted claims to the Horizon BCBSNJ Processing Systems. Submitter must correct rejected claim and resubmit for consideration. 8. Please submit your claims in one ST.SE per claim, this will prevent the rejection of an entire batch of claims if only one claim is not in compliance. When the 999 is returned for non-compliance, an error status will indicate the error location, allowing the submitter to correct and resubmit the entire file. 9. Submit the Horizon BCBSNJ Subscriber ID number as indicated on the insurance card. 10. Horizon BCBSNJ does not handle Payer to Payer COB. Payer to Payer COB is defined as the electronic transmission of the Horizon BCBSNJ finalized claim to a secondary payer for their consideration or vice versa. 11. Horizon BCBSNJ will process secondary COB claims received from a provider. These claims are defined as a primary carrier has processed the claim, and it is being submitted to Horizon BCBSNJ for secondary consideration. 12. Submission of Pay-To Provider information does not guarantee that payment will be made to that provider. Horizon BCBSNJ will make any payments based on contractual agreements previously established. 13. For Horizon BCBSNJ business, Home Infusion EDI Coalition (HIEC) Product/Services codes are not acceptable. Claims received with these codes will be rejected. SV202-1@Loop 2400 and SVD03-1@Loop Horizon BCBSNJ supports fast batch submission for primary claims only. 15. All claims submitted to Horizon BCBSNJ for secondary/tertiary consideration should only be submitted after the previous payer(s) have processed the claim. Blue Cross and Blue Shield Association January

22 16. Horizon BCBSNJ strongly suggests that the Patient Responsibility and Contractual Obligation information be submitted on secondary/tertiary claims, when appropriate. Loop Id Reference Implementation Name Codes Notes/Comments 1000A NM102 Entity Type A NM102 Entity Type A NM109 Submitter Identifier Not Used for Horizon BCBSNJ Institutional business. Used for Horizon BCBSNJ Institutional business. Submitter Tax ID number - positions 1-9 must be numeric. 1000B NM103 Receiver Name Use "Horizon BCBSNJ" for Horizon BCBSNJ business. 1000B NM109 Receiver Primary Identifier Must be "22099". 2000A 2010AA CUR N302 Foreign Currency Information Billing Provider Address Line 2010AB N302 Pay-to Address Line 2000B SBR09 Claim Filing Indicator Code 2010BA NM102 Entity Type BA NM104 Subscriber First Name 2010BA 2010BA NM108 NM109 Identification Code Subscriber Primary Identifier 2010BA N302 Subscriber Address Line 2010BA REF Property and Casualty Claim Number 2010BB NM103 Payer Name Identification Code 2010BB NM BB NM109 Payer Identifier 2010BB N3 Payer Address BL MI PI Horizon BCBSNJ accepts claims submitted in U.S. dollars only. Example: Floor, Apartment number, etc. Example: Floor, Apartment number, etc. Horizon BCBSNJ strongly recommends using this code for Horizon BCBSNJ institutional claims. Required for Horizon BCBSNJ business Must be used for Horizon BCBSNJ business Must be used for Horizon BCBSNJ business Must contain the Horizon BCBSNJ Subscriber ID number as indicated on the insurance card. Example: Floor, Apartment number, etc. Horizon BCBSNJ does not use Property and Casualty segments in claims processing. Claims submitted with Property and Casualty segments will be rejected. Must use "HORIZON BCBSNJ" for Horizon BCBSNJ business Must be used for Horizon BCBSNJ business Must be "22099" for Horizon BCBSNJ business Not needed for Horizon BCBSNJ business. Blue Cross and Blue Shield Association January

23 Loop Id Reference Implementation Name Codes Notes/Comments 2010BB 2010BB 2010CA REF REF01 REF 2300 PWK Payer Secondary Identification Reference Identification Property & Casualty Patient Identifier Claim Supplemental Information 2300 CN1 Contract Information 2300 REF Payer Claim Control Number G2 Not needed for Horizon BCBSNJ business. This is no longer a required field, however, the Billing Provider's 6 digit Medicare UPIN, if known, will not be rejected by Horizon BCBSNJ if sent. Horizon BCBSNJ will reject claims received with property and casualty information. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. Not used for Horizon BCBSNJ business. For Horizon BCBSNJ business, original ICN# must be submitted for adjustment claims and claims for late charges. Adjustment and late charge claims will be rejected if original ICN# is not submitted. 1. For Horizon BCBSNJ business, all institutional claims must be submitted with a Principal Diagnosis Code. Claims received without a Principal Diagnosis Code will be rejected. 2. For Horizon BCBSNJ business the principal diagnosis code is required and cannot have a V, W, X, or Y in the first position of the code. Claims received without a principal diagnosis code or with a V, W, X, or Y " in the first position of the code will be rejected HI Principal Diagnosis ABK 3. For Horizon BCBSNJ business, do not transmit any decimal points in any of the diagnosis code segments. The decimal point is assumed. Horizon BCBSNJ will reject claims received with a decimal point in the diagnosis code HI Admitting Diagnosis ABJ Required on all Inpatient Claims. Blue Cross and Blue Shield Association January

24 Loop Id Reference Implementation Name Codes Notes/Comments 2300 HI Patient's Reason For Visit APR 2300 HI01-01 Code List Code CAH E HI01-01 thru HI12-01 Code List Code BBQ N CAS01 Laboratory or Facility Address Line Claim Adjustment Group Code 2330A NM109 Other Insured Identifier 2330A 2330B 2330B N302 N302 DTP Other Insured Address Line Other Payer Address Line Claim Check Or Remittance Date CO,PR Required for claims involving Outpatient Visits. For Horizon BCBSNJ business, claims submitted using this qualifier will be rejected. For Horizon BCBSNJ business, claims for inpatient services must be submitted using this qualifier. Example: Floor, Apartment number, etc. Horizon BCBSNJ strongly recommends sending this information, to allow proper adjudication of the claim. For Horizon BCBSNJ business, the member's insurance ID# should be submitted exactly as seen on their ID Card to ensure the proper processing of their claim. Example: Floor, Apartment number, etc. Example: Floor, Apartment number, etc. Horizon BCBSNJ business requires that Medicare primary claims submitted for secondary consideration must contain the Claim Adjudication Date in this segment. If not submitted, the claim will be rejected. 2330B REF Other Payer Claim Control Number Horizon BCBSNJ business requires that Medicare primary claims submitted for secondary consideration must contain the Medicare original ICN # in REF02 of this segment, qualified by the F8 qualifier in REF01. Claims not submitted this way will be rejected. Blue Cross and Blue Shield Association January

25 Loop Id Reference Implementation Name Codes Notes/Comments 2400 SV SV SV PWK Service Line Revenue Code See Code Source 132: National Uniform Billing Committee (NUBC) Codes. Product/Service ID Product/Service ID Line Supplemental Information 2400 AMT Service Tax Amount 2400 AMT Facility Tax Amount 2400 HCP SVD CAS01 Product/Service ID Product/Service ID Claim Adjustment Group Code ER,WK,IV HC ER,WK,IV ER,WK,IV CO,PR For Horizon BCBSNJ business, when an outpatient claim is submitted with one of the following revenue codes, a HCPCS code is required: Claims will be rejected if not submitted correctly. Must NOT be used for Horizon BCBSNJ business. Horizon BCBSNJ requires the submission of "J" codes here. At this time, Horizon BCBSNJ will not utilize information submitted in the PWK segment of this transaction. If additional information is needed to process the claim, the provider will be contacted. For Horizon BCBSNJ business, tax amounts should be bundled with total charges. All claims submitted with separate tax segments will be rejected. For Horizon BCBSNJ business, tax amounts should be bundled with total charges. All claims submitted with separate tax segments will be rejected. Must NOT be used for Horizon BCBSNJ business. Must NOT be used for Horizon BCBSNJ business. Horizon BCBSNJ strongly recommends sending this information, to allow proper adjudication of the claim (i.e. Medicare Allowed Amount). Blue Cross and Blue Shield Association January

26 X224A2 Health Care Claim: 837 Dental Business Rules and Guidelines 1. When an NPI is obtained from CMS, it must be communicated to Horizon BCBSNJ so that it can be loaded to internal processing tables. This will allow for adequate processing of your transaction 2. All characters sent must be upper case. 3. All Patient Control numbers should be unique. 4. Submit the Horizon BCBSNJ Subscriber ID Number as indicated on the insurance card. 5. Refer to Appendix A for Horizon BCBSNJ Subscriber ID Format examples. 6. After receipt and acknowledgement response of the claims, a batch process will occur to forward all applicable claims to the back-end adjudication systems. 7. The batch process will occur four times a day at 7am (07:00), 10am (10:00), 1pm (13:00) and 4pm (16:00) Monday through Friday. 8. Horizon BCBSNJ will retrieve claims Sunday at 6:00 a.m. Tuesday - Saturday at 1:00 a.m. 9. A Claim Acknowledgement Response (277CA) will be available the next business day. If you do not receive the Acknowledgement response timely or if it does not represent all the transactions submitted, contact EDI EDI Service Desk at or the EDI Service Desk at <HorizonEDI@HorizonBlue.com>. The Acknowledgement transaction will give status on the previous claims transmitted to Horizon BCBSNJ and pass Horizon s compliance checking process. 10. A 999 will be utilized to indicate functional acknowledgement when a file/transaction is rejected for non-compliance. When a 999 is returned for noncompliance, an error status will appear to indicate the error location, allowing the submitter to correct and resubmit the entire file 11. The 999 will be available almost immediately allowing the submitter the opportunity to correct and re-submit that file before Horizon BCBSNJ s scheduled batch processing occurs. 12. Please submit your claims in one ST.SE per claim, this will prevent the rejection of an entire batch of claims if only one claim is not in compliance. When the 999 is returned for non-compliance, an error status will indicate the error location, allowing the submitter to correct and resubmit the entire file. 13. Rejected claims contained in the acknowledgement transaction will not be forwarded to Horizon BCBSNJ Claims Processing Systems. A batch containing rejected claims will forward only the accepted claims to the Horizon BCBSNJ Processing Systems. Submitter must correct rejected claim and resubmit for consideration. 14. If a Horizon BCBSNJ dental claim contains only Billing Provider information, the Billing Provider will be the payee. If the dental claim contains Billing Provider information and Pay To Provider information, the Pay To Provider will be the payee. Blue Cross and Blue Shield Association January

27 15. If you are a non-participating physician with Horizon BCBSNJ and wish to receive payment, you must submit a value of "Y" in the CLM08 data element. Although a "Y" is sent, payment is subject to the contractual agreement between Horizon BCBSNJ and the subscriber s group. For more information the submitter must contact the customer service number on the back of the member's ID card. 16. If you are submitting a predetermination of benefits, please do not value ANY DTP segments on this transaction. 17. Horizon BCBSNJ requires all dental claims be submitted is US Dollars only. Horizon BCBSNJ cannot process claims that are not in US Dollars. Therefore, claims will be rejected. 18. Horizon BCBSNJ will process secondary COB claims. These claims are defined by where a primary carrier has processed the claim, and it is being submitted to Horizon BCBSNJ for secondary consideration. 19. Horizon BCBSNJ does not handle Payer to Payer COB. Payer to Payer COB is defined as the electronic transmission of the Horizon BCBSNJ finalized claim to a secondary payer for their consideration or vice versa. 20. All claims submitted to Horizon BCBSNJ for secondary/tertiary consideration should only be submitted after the previous payer(s) have adjudicated the claim. COB claims received without the Other Payer Claim Paid Date (DTP in Loop 2330B) will be rejected. 21. Submission of Pay-To-Provider information does not guarantee that payment will be made to that provider. Horizon BCBSNJ will make any payments based upon contractual agreements previously established. UNIQUE requirements for the Federal Employees Program: o The following types of 837 Dental transactions cannot be processed by Horizon BCBSNJ for Federal Employees and will be rejected: 1. Predetermination of Benefits 2. Encounters Blue Cross and Blue Shield Association January

28 Loop Id Reference Implementation Name 1000A NM109 Submitter Identifier 1000B NM103 Receiver Name 1000B 2000A 2010AA 2010AA 2010AC 2010AC NM109 CUR NM104 REF01 NM108 NM109 Receiver Primary Identifier Foreign Currency Information Billing Provider First Name Codes Notes/Comments For Horizon BCBSNJ, must contain Submitter Tax ID#. Use "Horizon BCBSNJ" for Horizon BCBSNJ business Must contain Horizon BCBSNJ Payer ID# "22099" Horizon BCBSNJ requires all dental claims be submitted in US dollars only. Horizon BCBSNJ cannot process claims that are not in US dollars. Therefore, these claims will be rejected. Must be used for Horizon BCBSNJ business Reference Identification EI Must be used for Horizon BCBSNJ business. Identification Code PI Must use for Horizon BCBSNJ business Pay-to Plan Primary Identifier Must be "22099" for Horizon BCBSNJ business 2000B SBR01 Payer Responsibility Sequence Number Code For Horizon BCBSNJ business, if "S" or "T" are present, the submitter must value AMT02 in Loop 2320 or SVD02 in Loop BA NM102 Entity Type 1 Used for Horizon BCBSNJ business 2010BA 2010BA 2010BA 2010BA NM104 NM108 NM109 REF Subscriber First Name Must be sent for Horizon BCBSNJ business Identification Code MI Must be used for Horizon BCBSNJ business Subscriber Primary Identifier Property and Casualty Claim Number 2010BB NM103 Payer Name 2010BB NM BB NM109 Payer Identifier For Horizon BCBSNJ business, the member's dental insurance ID# should be submitted exactly as seen on their ID Card to ensure the proper processing of their claim. Horizon BCBSNJ does not use Property and Casualty segments in claims processing. Claims submitted with Property and Casualty segments will be rejected. Should contain "Horizon Blue Cross Blue Shield of NJ" Identification Code PI Must be used for Horizon BCBSNJ business For Horizon BCBSNJ business, must be "22099" 2010BB REF Billing Provider Secondary Identification For Horizon BCBSNJ business, the Billing Provider's three digit multiple office location code, if known, should be submitted in REF segment, qualified by a value of 'G2' or 'LU'. Blue Cross and Blue Shield Association January