COMMONWEALTH CARE ALLIANCE CCA COMPANION GUIDE

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1 COMMONWEALTH CARE ALLIANCE CCA COMPANION GUIDE

2 PREFACE This Companion Guide is v5010 and ASC X12N compatible and adopted under HIPAA clarifies and specifies the data content when exchanging electronically with CCA. Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides. All rights reserved Page 3

3 Table of Contents INTRODUCTION... 6 SCOPE... 6 CONTROL SEGEMENTS AND ENVELOPE... 6 ISA-IEA... 6 GS-GE... 6 ST-SE... 6 PAYER SPECIFICATION BUSINESS RULES AND LIMITS... 6 Report Inventory... 7 Trading Partner Agreements... 7 Trading Partners... 7 TRANSACTION SPECIFIC INFORMATION... 7 TRANSACTION INFORMATION... 7 Test File # Test File # Test File # SYSTEM OVERVIEW... 8 MINIMUM SYSTEM REQUIREMENTS... 8 DATA VERIFICATION... 8 CONTACT INFORMATION... 8 IMPORTANT REMINDERS FOR SUCCESSFUL CLAIMS ADJUDICATION CONTROL SEGEMENT... 9 ISA- INTERCHANGE CONTROL HEADER... 9 GS- FUNCTIONAL GROUP HEADER... 9 ST- HEADER BHT-BEGIN HIERARCHICAL TRANSACTION A SUMITTER NAME A SUBMITTER EDI CONTACT INFORMATION B BILLING PROVIDER HIERARCHICAL LEVEL A BILLING PROVIDER HIERARCHICAL LEVEL AA BILLING PROVIDER NAME AA BILLING PROVIDER TAX IDENTIFICATION AA BILLING PROVIDER ADDRESS AA BILLING PROVIDER CITY/STATE/ZIP AA PAY-TO NAME AA - PAY- TO ADDRESS B SUBSCRIBER HIERARCHICAL LEVEL B SUBSCRIBER INFORMATION BA SUBSCRIBER NAME BA SUBSCRIBER ADDRESS Loop ID Reference ID Reference Description Notes/Comments BA SUBSCRIBER CITY/STATE/ZIP CODE BA SUBSCRIBER DEMOGRAPHIC INFORMATION All rights reserved Page 4

4 2010BB- PAYER NAME BB- BILLING PROVIDER SECENDORY ID C - PATIENT HIERARCHICAL LEVEL Do NOT Submit this Segment HEALTH CLAIM SERVICE AUTHORIZATION EXCEPTION CODE PAYER CLAIM CONTROL NUMBER (for Voids/Replacements) A - REFERRING PROVIDER NAME A REFERRING PROVIDER SECONDARY I.D B RENDERING PROVIDER NAME B - RENDERING PROVIDER SPECIALITY B - RENDERING PROVIDER SECONDARY IDENTIFICATION C - SERVICE FACILITY LOCATION NAME C SERVICE FACILITY LOCATION ADDRESS C - SERVICE FACILITY LOCATION CITY/STATE/ZIP CODE B - CLAIM CHECK OR REMITTANCE DATE HEALTH CLAIM (a.k.a. PROFESSIONAL SERVICE) PRIOR AUTHORIZATION NUMBER DRUG IDENTIFICATION DRUG QUANTITY PRESCRIPTION, OR COMPOUND DRUG ASSOC NUMBER A - RENDERING PROVIDER NAME A - RENDERING PROVIDER SECONDARY SPECIALTY INFORMATION A - RENDERING PROVIDER SECONDARY IDENTIFICATION LINE ADJUDICATION INFORMATION (for COB) SE - TRANSACTION SET TRAILER GE - FUNCTIONAL GROUP TRAILER IEA - INTERCHANGE CONTROL TRAILER DISCLAIMER All rights reserved Page 5

5 INTRODUCTION The Administrative Simplification provision of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the Department of Health and Human Services (HHS) establish national standards for electronic health care transactions for health plans and providers. The 837 X12N Implementation Guides were implemented as the standard documents to be used in order to comply with claims transaction compliance for electronic data interchange in health care. TPA (Third Part Administrator) has prepared this document as a guide to the data elements and segment requirements for electronic claim submissions. The intended audience for this document should be the technical team responsible for creating the specifications needed to submit a HIPAA compliant electronic claims file. This information should be coordinated with the healthcare provider s billing practice to ensure accuracy and completion of all necessary data requirements. SCOPE For the health care industry to achieve the potential administrative cost savings with Electronic Data Interchange (EDI), standards have been developed and need to be implemented consistently by all organizations. To facilitate a smooth transition into the EDI environment, uniform implementation is critical. This is the technical report document for the ANSI ASC X12N 837 Health Care Claims (837) transaction for professional claims and/or encounters. This document provides a definitive statement of what trading partners must be able to support in this version of the 837. This document is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated CONTROL SEGEMENTS AND ENVELOPE ISA-IEA This section describes TPA s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information, and delimiters. GS-GE This section describes CCA s use of the functional group control segments. It includes a description of expected application sender and receiver codes. Also included in this section is a description concerning how CCA expects functional groups to be sent and how TPA will send functional groups. These discussions will describe how similar transaction sets will be packaged and CCA s use of functional group control numbers. ST-SE This section describes TPA s use of transaction set control numbers. PAYER SPECIFICATION BUSINESS RULES AND LIMITS This section describes CCA s business rules, for example: 1. Billing for specific services such as DME, Ambulance, Home Health 2. Communicating payer specific edits 3. CORE Level of Certification Acknowledgements and/or Reports This section contains information and examples on any applicable payer acknowledgements All rights reserved Page 6

6 Report Inventory This section contains a listing/inventory of all applicable acknowledgement reports Trading Partner Agreements This section contains general information concerning Trading Partner Agreements (TPA). An actual TPA may optionally be included in an appendix Trading Partners An EDI Trading Partner is defined as any CCA customer (provider, billing service, software vendor, employer group, financial institution, etc.) that transmits to, or receives electronic data from CCA. Payers have EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement. For example, a Trading Partner Agreement may specify among other things, the roles and responsibilities of each party to the agreement in conducting standard transactions. TRANSACTION SPECIFIC INFORMATION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that CCA has something additional, over and above, the information in the IGs. That information can: 1. Limit the repeat of loops, or segments 2. Limit the length of a simple data element 3. Specify a sub-set of the IGs internal code listings 4. Clarify the use of loops, segments, composite and simple data elements 5. Any other information tied directly to a loop, segment, and composite or simple data element pertinent to trading electronically with CCA. In addition to the row for each segment, one or more additional rows are used to describe CCA s usage for composite and simple data elements and for any other information. Notes and comments should be placed at the deepest level of detail. For example, a note about a code value should be placed on a row specifically for that code value, not in a general note about the segment. TRANSACTION INFORMATION TPA requires the creation of a claims file from your source claiming system. It must meet the requirements outlined in Steps. TPA will work with you and your key staff to successfully submit test claims files to a non-production environment in a three-phased approach. TPA requires you to submit test claim files to a non-production environment. When each test file passes all HIPAA, claims validations and related testing requirements, you will obtain certification for your Agency s EDI transactions from the TPA. Test File #1 The purpose of this test file to complete and pass all HIPAA edits. Items such as the Header (ISA segments) and Footer (trailer) along with field lengths specified in the 5010 Implementation Guide. All rights reserved Page 7

7 Test File #2 The purpose of the test file is to complete and pass all HIPAA edits (specified above) along with claim segment requirements. Example of segments are; length requirements within each segment, alpha and numeric characters. This file should be with accurate billing provider, pay to provider, member data and true claim data. The CCA will provide the agency with a 999 files (acceptance and/or denial) acknowledgment. Test File #3 The purpose of the test file is to complete and pass all HIPAA edits (specified above) along with claim segment requirements and to perform a full cycle testing with the Medicaid system. This file should be with accurate billing provider, pay to provider, member data and true claim data. The TPA will submit your passable claims to Medicaid who will then review and adjudicate the file returning an 835 file. The TPA will then merge the Medicaid 835 file with the TPA denials and submit a combined 835 file to the agency. The TPA will provide the agency with a 999 files (acceptance and/or denial) acknowledgment. SYSTEM OVERVIEW Claims Administrator (CA) used in conjunction with EZNET/Submitter Services will facilitate the submission of claims data from providers, or their designated entities (i.e. clearinghouses) into the EZ-CAP claims processing system. Claims can currently be received in the 837P and 837I format. MINIMUM SYSTEM REQUIREMENTS Windows 2000 SP3, XP, 7 Internet Explorer 5.0, 7.0, 8.0 DATA VERIFICATION All submitters will be required to present test transmissions to verify the integrity of the data being sent before "Live" transmissions are allowed. This will be coordinated through our Technical contact below. CONTACT INFORMATION Name Position/Dept. Address CCA EDI Support EDI Technical Assistance ccaedisupport@pcgus.com IMPORTANT REMINDERS FOR SUCCESSFUL CLAIMS ADJUDICATION Validation of the member identification number is essential. If this number is not provided or is incorrect, the claim will be rejected. Claims requiring attachments (medical documentation, invoices, etc.) cannot be submitted via EDI at this time. ICD-9 diagnosis coding must be submitted to the highest level of specificity. All codes should be submitted with a fourth and/or fifth digit when appropriate to the medical condition. o Diagnosis codes must contain decimal points in the 837 format submissions o TPA can accept up to 18 diagnosis codes at this time Modifiers must be included next to the CPT/HCPCS code on the line item where applicable. Pricing modifiers should be applied in the 1 st modifier position to ensure appropriate pricing rules. Please ensure that multiple modifiers are separated by HIPAA delimiting characters. All rights reserved Page 8

8 837 CONTROL SEGEMENT ISA- INTERCHANGE CONTROL HEADER HEADER ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange-related control segments. HEADER ISA01 /I01 Authorization Information Use: 00 (Additional Data Identification). HEADER ISA02 /I02 Authorization Information Enter: 10 Spaces HEADER ISA03 /I03 Security Information Use: 00 (No security information present) HEADER ISA04 /I04 Security Information Enter: 10 Spaces HEADER ISA05 /I05 Interchange ID Required, identifies the information in ISA06. Use: ZZ (Mutually Defined). HEADER ISA06 /I06 Interchange Sender ID Enter the submitter ID provided to you by TPA s EDI department during the EDI Enrollment process Fill 15 Positions. Do not use leading zeros. Right fill with spaces to keep length at 15 characters. HEADER ISA07 /I05 Interchange ID Identifies the information in ISA08. HEADER ISA08 /I07 Interchange Receiver ID Enter the Receiver ID provided to you by TPA s EDI department during the EDI Enrollment process Fill 15 Positions. Do not use leading zeros. Right fill with spaces to keep length at 15 characters. HEADER ISA09 /I08 Interchange Date Enter: Date of the Interchange YYMMDD HEADER ISA10 /I09 Interchange Time Enter: Time of the Interchange HHMM HEADER ISA11 /I10 Interchange Control Enter: ^ (carat) HEADER ISA12 /I11 Standard Interchange Control Version Number HEADER ISA13 /I12 Interchange Control Number Enter: (for US EDI ASCI X12) Enter: Unique 9 Digit Number Assigned by Sender Can be HEADER ISA14 /I13 Acknowledgement Requested Enter: 0 HEADER ISA15 /I14 Usage Indicator P or T (P = Production T = Test) HEADER ISA16 /I15 Element Separator Enter: : (Colon) GS- FUNCTIONAL GROUP HEADER HEADER GS Functional Group Header To indicate the beginning of a functional group and to provide control information. HEADER GS01 / 479 Functional Identifier Code Enter: HC (for Health Care Claim (837) HEADER GS02 / 142 Application Sender Code Use your Submitter ID. This is the same code as used in HEADER GS03 / 124 Application Receiver Code ISA06 Enter receiver ID provided by TPA HEADER GS04 /373 Date Enter: Transaction Creation Date CCYYMMDD HEADER GS05 /337 Time Enter: Transaction Time 24Hr Military Clock HHMM HEADER GS06 /28 Group Control Number Enter: Assigned Number by the Sender, Must be Same as in HEADER GS07 /455 Responsible Agency Code GE02 Enter: Group X (for Trailer American Standards Committee X12) All rights reserved Page 9

9 HEADER GS08 /480 Version/Release/Industry Identifier Code Enter: X222A1 (Draft Approved Standard for X ) ST- HEADER HEADER ST Transaction Set Header to transmit one or more claims per billing provider HEADER ST01 / 143 Transaction Set Code Enter: "837" (for Health Care Claim (837) HEADER HEADER ST02 / 329 ST03 Transaction Set Control Number Version/Release/Industry Identifier Code Enter: Assigned Number by the Sender Must be Same as in SE02 Trailer, minimum 4, maximum 9 characters. Enter: X222A1 (Draft Approved Standard for X ) BHT-BEGIN HIERARCHICAL TRANSACTION HEADER BHT Begin Transaction Set Header Designed to transmit one or more claims per billing provider HEADER BHT01/353 Hierarchical Structure Code Enter: "0019" (Information Source, Subscriber Dependent) HEADER BHT02 / 127 Transaction Set Purpose Code Enter: "00" (for original issue) HEADER BHT03/127 Reference Identification Enter: (Same as in ST02) HEADER BHT04/373 Date Enter: Transaction Creation Date CCYYMMDD HEADER BHT05/337 Time Enter: Transaction Time 24Hr Military Clock HHMM HEADER BHT06 /640 Transaction Type Code Enter: "CH" (for Chargeable) 1000A SUMITTER NAME 1000A NM1 Begin Transaction Set Header To Supply the Full Name of an Organization 1000A NM101 / 98 Entity Identifier Code Enter: "41" (Submitter) 1000A NM102/ Entity Type Enter: "2" (for non-person entity) or "1" (for a person) 1000A 1065 Name Last or Organization Enter: If an entity - (Submitter Name), If a person (Enter NM103 /1035 Name Last Name) 1000A NM104 / 1036 Name - First Enter: Only if a person 1000A NM105 /1037 Name - Middle Enter: Only if a person 1000A NM106 /1038 Name - Prefix Enter: Only if a person 1000A NM107 /1039 Name - Suffix Enter: Only if a person 1000A NM108 /66 Identification Code Enter: "46" (for ETIN established by trading patient agreement) 1000A NM109 /67 Identification Code Enter: Submitter ID This is the same code as used in ISA A SUBMITTER EDI CONTACT INFORMATION 1000A PER EDI Communications Contact To Identify a person or office to whom administrative communications should be directed 1000A PER01 /366 Contact Function Code Enter: "IC" (Information Contact) 1000A PER02 / 93 Contact Name Enter: (Submitter Contact Name) All rights reserved Page 10

10 1000A PER03 /365 Communication Number Enter: "TE" (for Telephone Number) 1000A PER04 /364 Communication Number Enter: (Phone Number including country or area code where applicable) Loop ID Reference Name Notes/Comments 1000B BILLING PROVIDER HIERARCHICAL LEVEL 1000B NM1 Begin Transaction Set Header To Supply the Full Name of an Organization 1000B NM101 / 98 Entity Identifier Code Enter: "40" (Receiver) 1000B NM102/1065 Entity Type Enter: "2" (for non-person entity) 1000B NM103/1035 Last or Organization Name Receiver s Organization 1000B NM104/1036 Name - First Enter: * 1000B NM105/1037 Name - Middle Enter: * 1000B NM106/1038 Name - Prefix Enter: * 1000B NM107/1039 Name - Suffix Enter: * 1000B NM108 /66 Identification Code Enter: "46" (for ETIN established by trading agreement) 1000B NM109 /67 Identification Code Enter same as ISA A BILLING PROVIDER HIERARCHICAL LEVEL 2000A HL Billing/Pay-to Provider To identify dependencies among the content of Hierarchical Level hierarchically related groups of data segments 2000A HL01 / 628 Hierarchical Identifier Code Enter: Must begin with a "1" and increment by one each time an HL Segment is used. This will typically be a '1' 2000A HL02/ 734 Hierarchical Parent Identifier Code Enter "*" 2000A HL03 / 735 Hierarchical Level Code Enter: "20" (for information source) 2000A HL04 /736 Hierarchical Child Code Enter: "1" (to indicate additional subordinate HL Data Segment used) 2010AA BILLING PROVIDER NAME 2010AA NM1 Begin Transaction Set Header To Supply the Full Name of an Organization 2010AA NM101 / 98 Entity Identifier Code Enter: "85" (Billing Provider) 2010AA NM102 /1065 Entity Type Enter: "2" (for non-person entity) or "1" (for a person) 2010AA NM103 /1035 Name Last or Organization Name 2010AA NM104 /1036 Name - First Enter: (if a person) 2010AA NM105 /1037 Name - Middle Enter: (if a person) Enter: If an entity - (Billing Provider Name) If a person (Last Name) 2010AA NM106 /1038 Name - Prefix Enter: * 2010AA NM107 /1039 Name - Suffix Enter: * 2010AA NM108 /66 Identification Code Enter: "XX" (for National Provider Identification NPI) 2010AA BILLING PROVIDER TAX IDENTIFICATION 2010AA REF Billing Provider Tax Identification To specify the Billing Provider s tax identification. It is used for IRS 1099 Income Reporting. All rights reserved Page 11

11 REF01 / Reference Identification Use the qualifier EI to identify the Employer Tax I.D. Use 2010AA the qualifier SY to identify Social Security Number 2010AA REF02 / Reference Additional I.D. Enter tax identification number (no dashes) 2010AA BILLING PROVIDER ADDRESS 2010AA N3 Billing Provider Address To Specify the location of the named party 2010AA N301 / 166 Address Information Enter: (Billing Provider Address Line 1) 2010AA N302 /166 Address Information Enter: (Billing Provider Address Line 2) if it exists 2010AA BILLING PROVIDER CITY/STATE/ZIP 2010AA N4 Billing Provider City/State/Zip To Specify the location of the named party 2010AA N401 / 19 City Name Enter: (Billing Provider City Name) 2010AA N402/156 State or Province Code Enter: (Billing Provider State Code) 2010AA N403/116 Postal Code Enter: (Billing Provider Zip Code) 2010AA N404/26 Country Code Required if Address is outside of US 2010AA PAY-TO NAME 2010AA NM1 Begin Transaction Set Header To Supply the Full Name of an Organization 2010AA NM101 / 98 Entity Identifier Code Enter: "87 (Pay- To Provider) 2010AA NM102/1065 Entity Type Enter: "2" (for non-person entity) or "1" (for a person) 2010AA NM103/1035 Name Last or Organization Enter: If an entity - (Pay-To Provider Name), If a person Name (Last Name) 2010AA NM104/1036 Name - First Enter: (If NM102 = "1" person Enter Last Name) 2010AA NM105/1037 Name - Middle Enter: (If NM102 = "1" person Enter Middle Name) 2010AA NM106/1038 Name - Prefix Enter: * 2010AA NM107/1039 Name - Suffix Enter: * 2010AA NM108 /66 Identification Code Enter: XX" NPI 2010AA - PAY- TO ADDRESS 2010AA N3 Pay To Provider Address To Specify the location of the named party 2010AA N301 / 166 Address Information Enter: (Pay To Provider Address Line 1) 2010AA N302 /166 Address Information Enter: (Pay To Provider Address Line 2) if it exists 2000B SUBSCRIBER HIERARCHICAL LEVEL 2000B HL Subscriber Hierarchical Level 2000B HL01/ 628 Hierarchical Identifier Code 2000B HL02/ 734 Hierarchical Parent Identifier Code To identify dependencies among the content of hierarchically related groups of data segments Enter: Must begin with a "1" and increment by one each time an HL Segment is used. This will typically be a '2' because of the prior Provider Level Segment. Enter : '1' All rights reserved Page 12

12 2000B HL03 / 735 Hierarchical Level Code Enter: "22" (for subscriber) 2000B HL04 /736 Hierarchical Child Code 2000B SUBSCRIBER INFORMATION 2000B SBR Subscriber Information 2000B SBR01/1138 Payer Responsibility Sequence Code 2000B SBR02/1069 Individual Relationship Code Enter : '18' (for self) 2000B SBR03 /127 Reference Identification 2000B SBR04 /93 Free Form Name Enter: "0" (to indicate no subordinate HL Data Segments used) To identify information specific to the primary insured and the insurance carrier for that insured. Enter: Insurance carriers level of payment responsibility: 'P' Primary 'S' Secondary 'T' Tertiary Enter: Insured Group or Plan Name if the subscribers payer id includes a Group or Plan Name 2010BA SUBSCRIBER NAME 2010BA NM1 Begin Transaction Set Header To Supply the Full Name of a Individual or Organization 2010BA NM101 / 98 Entity Identifier Code Enter: "IL (Insured or Subscriber) 2010BA NM102 / 1065 Entity Type Enter: "1" (for person entity) "2" (for non-person entity) 2010BA NM103 /1035 Last or Organization Name Enter: (Subscriber Last Name or Organization Name) 2010BA NM104 /1036 Name - First Enter: (If NM102 = '1' Person Enter First Name) 2010BA NM105 /1037 Name - Middle Enter: (If NM102 = '1' Person Enter Middle Name) 2010BA NM106 /1038 Name - Prefix Enter: * 2010BA NM107 /1039 Name - Suffix Enter: * 2010BA NM108 /66 Identification Code Enter: "MI" (Required if NM102 = "1" Else Enter *) 2010BA NM109 /67 Identification Code Enter: (Subscriber/Member ID ) Loop ID Reference ID Reference ID Notes/Comments 2010BA SUBSCRIBER ADDRESS 2010BA N3 Subscriber Address To Specify the location of subscriber 2010BA N301 / 166 Address Information Enter: (Subscriber Address Line 1) 2010BA N302 /166 Address Information Enter: (Subscriber Address Line 2) 2010BA SUBSCRIBER CITY/STATE/ZIP CODE 2010BA N4 Subscriber City/State/Zip To Specify the location of the subscriber 2010BA N401 / 19 City Name Enter: (Billing Subscriber City Name) 2010BA N402/156 State or Province Code Enter: (Billing Subscriber State Code) 2010BA N403/116 Postal Code Enter: (Billing Subscriber Zip Code) 2010BA N404/26 Country Code Required if Address is outside of US 2010BA SUBSCRIBER DEMOGRAPHIC INFORMATION 2010BA DMG Subscriber s Demographic Required if the patient is the same person as the subscriber. All rights reserved Page 13

13 info (Loop SBR02 = 18 (self)) 2010BA DMG01/1250 Date Time Period Enter: "D8" 2010BA DMG02/1251 Subscriber Birth Date Patient Birth Date in CCYYMMDD Format 2010BA DMG03/1068 Gender Code Enter: "F" (female), "M" (Male), "U" (unknown) 2010BB- PAYER NAME 2010BB NM1 Begin Transaction Set Header Supply the Full Name of the Destination Payer 2010BB NM101/98 Entity Identifier Code Enter: "PR" (Payer) 2010BB NM102/1065 Entity Type Enter: "2" (for non-person entity) 2010BB NM103 /1035 Name Last or Organization Enter: "Public Consulting Group" 2010BB NM104 /1036 Name Name - First Enter: First name 2010BB NM105 /1037 Name Middle Enter: Middle name 2010BB NM106 /1038 Name - Prefix 2010BB NM107 /1039 Name Suffix 2010BB NM108 /66 Identification Code Enter: "PI" (Payer Identification) 2010BB NM109 /67 Identification Code Enter Identification Code Loop ID Reference ID Reference ID Notes/Comments 2010BB- BILLING PROVIDER SECENDORY ID 2010BB REF Billing Provider Secondary 2010BB REF BB REF02 Identifier Reference Identification New, optional, segment to provide more granularities, especially with Medicare crossover claims. Use either the qualifier G2 to identify Provider Commercial Number (This replaces 4010 s 1D ) Or enter LU for location number. If it is a crossover claim, insert the Billing Provider s Medicare Number here. Otherwise, insert the Billing Provider s Medicaid I.D. number. 2000C - PATIENT HIERARCHICAL LEVEL Do NOT Submit this Segment 2000C HL Segment NOT applicable to Medicaid Claims since the subscriber is always the patient. Claims submitted with this segment will be returned Loop ID Reference ID Reference Notes/Comments Description 2300 HEALTH CLAIM 2300 CLM Health Claim To supply basic claim data 2300 CLM01/ 1028 Claim Submitter's Identifier 2300 CLM02/782 Monetary Amount Enter: Agency Unique Claim Identifier (Necessary for posting Remittances Advice Data for your internal system) Enter: Total Claim Charge Amount. Claims with amounts greater than $9,999, will be returned to provider. All rights reserved Page 14

14 2300 CLM05/C023 Health Care Service Location (CLM05 is a composite data element separated by a colon ) ":" (see below) 2300 CLM05-1/1331 Facility Code Value '11' Office '12' Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 20 Urgent Care Facility 21' Inpatient Hospital '22' Outpatient Hospital '23' Emergency Room '24' Ambulatory Surgical Center '25' Birthing Center '26' Military Treatment Center '31' Skilled Nursing Facility '32' Nursing Facility '33' Custodial Care Facility '34' Hospice '41' Ambulance Land '42' Ambulance Air or Water 49 Independent Clinic '50' Federally Qualified Health Center '51' Inpatient Psychiatric Facility '52' Psychiatric Facility Partial Hospitalization '53' Community Mental Health Center '54' Intermediate Care Facility/Mentally Retarded '55' Residential Substance Abuse Treatment Facility '56' Psychiatric Residential Treatment Center '60' Mass Immunization Center '61' Comprehensive Inpatient Rehabilitation Facility '62' 'Comprehensive Outpatient Rehabilitation Facility '65' End Stage Renal Disease Treatment Facility '71' State or Local Public Health Clinic '72' Rural Health Clinic '81' Independent Lab '99' Other Unlisted Facility 2300 CLM05-2 /1332 Facility Code Enter B for professional or dental 2300 CLM05-3/1325 Claim Frequency Code Claim Frequency Type Code for TPA Enter 1 (for original claim) Enter 7 (for replacement of prior claim) Enter 8 (for Void/Cancel of prior claim) 2300 CLM06 Provider or Supplier Enter Y 2300 CLM07 signature Provider Accept indicator Assignment Enter A 2300 CLM08 Code Benefit assignment Enter Y 2300 CLM09 certification Release of Information indicator code Enter Y 2300 CLM12/ Special Program Indicator NOTE: EPDST indicator, that used to be stored in this field, is now stored at the service line level, SV1-11, Loop For Waiver Services ONLY, enter 03, Special Federal Funding Code for Medicaid only SERVICE AUTHORIZATION EXCEPTION CODE All rights reserved Page 15

15 2300 REF Service Authorization Exception 2300 REF01 Reference Identification 2300 REF02 Reference Additional I.D. Required when prior authorization was mandated. Yet, for TPA listed below, in REF02, the required authorization was not obtained. Enter 4N Enter the most appropriate numerical code: 3 Emergency Care 6 Request for Override Pending 7 Special Handling 5 County requested a second opinion before recipient can return to work 2300 PAYER CLAIM CONTROL NUMBER (for Voids/Replacements) 2300 REF Payer Claim Control Number Situational Segment. Used in conjunction with the value in CLM5-03. If field CLM5-03 indicated that it is a replacement or void of a previously paid claim, then this segment is required. Note: This segment cannot be used until voids and replacement claims is submitted in the 837 format REF01 / Reference Identification Enter F8 to indicate that original reference number is being provided (below.) 2300 REF02 / Original Reference Number. Enter the 17-digit transaction control number (TCN) assigned by the adjudication system and printed on the remittance advice - - for the claim that is being replaced, or voided, by this new claim. Loop ID Reference Name Notes/Comments 2310A - REFERRING PROVIDER NAME 2310A NM1 Begin Transaction Set Full Name of the Referring Provider 2310A NM101 / Header Entity Identifier Code Enter: DN to indicate Referring Provider 2310A NM102 Entity Type Enter: 2 (for non-person entity) or 1(for a person) 2310A NM103 / Name Last or Organization Name Can be up to 60 characters long. If an entity - (Billing Provider Name) If a person (Last Name) 2310A NM104 / Name First Enter: (if a person). (Can be up to 35 characters long.) Else Enter: * 2310A NM105 / Name Middle Enter: (if a person), else Enter: * 2310A NM106 / Name Prefix Enter: * 2310A NM107 / Name Suffix Enter: * 2310A NM108 / Identification Code 2310A NM109 / Identification Code Enter: NPI Enter: XX (National Provider Number NPI) Note: 24 is no longer allowed 2310A REFERRING PROVIDER SECONDARY I.D All rights reserved Page 16

16 2310A REF Referring Provider Secondary New, optional, segment used to provide more granularity, especially with Medicare crossover claims. 2310A REF01 / Reference Identification Use either the qualifier G2 to identify Provider Commercial Number (This replaces 4010 s 1D ). 2310A REF02 / Identifier Employer s Identification Number. 2310B RENDERING PROVIDER NAME 2310B NM1 Rendering Provider To Supply the Full Name of Rendering Provider at the claim level 2310B NM101 / Entity Identifier Code Enter: B NM102 Entity Type Enter: 2 (for non-person entity) 2310B NM103 / Name Last or Organization Enter: Organization Name 2310B NM108 / Name Identification Code Enter XX to indicate that unique School Code will follows. 2310B NM109 / Identification Code Enter Organization s NPI number 2310B - RENDERING PROVIDER SPECIALITY 2310B PRV Rendering Provider Specialty Information Required when Rendering Provider shares an NPI number. When NPI number is shared, this segment is used to find the matching Medicaid I.D. 2310B PRV01 Provider Code Use the qualifier PE to indicate Rendering Provider. 2310B PRV02/ Reference Identification 2310B PRV03/ Reference Identification 2310B - RENDERING PROVIDER SECONDARY IDENTIFICATION 2310B 2310B REF REF01128 Rendering Provider Secondary Identification Reference Identification 2310B REF02/156 Reference Identification Use the qualifier PXC to indicate health care provider taxonomy code. Use the taxonomy code that is on file with us for Rendering Provider. Required if something other than NPI is needed to identify the rendering provider at the claim level. Choose from one of the following two character codes: 0B (Zero B) State License Number LU Location Number 1G (One G) Provider UPIN number (UPIN is formatted as either X99999 or XXX999) G2 Commercial Provider Number (Replaces code 1D in 4010) If an atypical provider, use Medicaid Provider I.D. If a health care provider, use employer s I.D. number C - SERVICE FACILITY LOCATION NAME All rights reserved Page 17

17 2310C NM1 Begin Transaction Set Header Usage is Situational. Identifies where the service was performed 2310C NM101 / Entity Identifier Code Enter: 77 (Service Location) 2310C NM102 Entity Type Enter: 2 (for non-person entity) 2310C NM103 / Name Last or Organization Name Can be up to 60 characters long. Enter: Location Name where the service(s) was performed 2310C SERVICE FACILITY LOCATION ADDRESS 2310C N3 Service Facility Location Address 2310C N301 / 166 Address Information 2310C N302 /166 Address Information Usage is Situational. To Specify the location of the service facility 2310C - SERVICE FACILITY LOCATION CITY/STATE/ZIP CODE Service Facility Location Usage is Situational. To Specify the location of the service 2310C N4 City/State/Zip Code facility 2310C N401 / 19 City Name Enter: (Service Facility Location City Name) 2310C N402/156 State or Province Code Enter: (Service Facility Location State Code) 2310C N403/116 Postal Code Enter the 9 digit Service Facility Location zip code. If the last 4 digits are not available, then fill those digits with zeros. 2310C N404/26 Country Code Required if Address is outside of US 2330B - CLAIM CHECK OR REMITTANCE DATE 2330B DTP Dater Optional Segment. Required when the other payer has previously adjudicated the claim and the segment for Loop 2430 is not provided. 2330B DTP01 Qualifying Code If used, enter 573 (other payer date claim paid.) 2330B DTP02 Date/Time Format If used, enter D8 to indicate the format of the next field 2330B DTP03/ Date. If used, enter adjudication of payment date. Format of this field must be: CCYYMMDD HEALTH CLAIM (a.k.a. PROFESSIONAL SERVICE) All rights reserved Page 18

18 2400 SV1 Professional Service Required. To specify the claim service detail for a Health Care professional 2400 SV101/ Medical I.D. Composite medical procedure I.D 2400 SV101-1/ Enter HC for Health Care Financing Administration Common Procedural Coding System (HCPCS) codes SV101-2/ Procedure Code Enter the procedure code for this service line SV101-3/ Procedure Code Modifier 2400 SV101-4/ Procedure Code Modifier 2400 SV101-5/ Procedure Code Modifier 2400 SV101-6/ Procedure Code Modifier If applicable, enter the procedure modifier for this service line. Note: If there are any Pricing Modifiers, then they should be entered in this field. If applicable, enter the procedure modifier for this service line. Note: Pricing Modifiers should not be entered here, but entered in SV101-3 (above). If applicable, enter the procedure modifier for this service line. Note: Pricing Modifiers should not be entered here, but entered in SV101-3 (above). If applicable, enter the procedure modifier for this service line. Note: Pricing Modifiers should not be entered here, but entered in SV101-3 (above) SV102/ 402 Monetary Amount Monetary Amount Note1: Drug Unit Prices are entered into this field. (Drug Unit Prices used to be entered in the CTP03 element of Loop 2410.) Note2: Claims submitted with amounts that are more than $9,999, will be returned to the submitter SV103/355 Unit or Basis measurement code 2400 SV104/ 380 Quantity 2400 SV111/ Early& Periodic screen for diagnosis & treatment of children (EPSDT) involvement Enter : 4N Enter: The claim service unit rounded to the nearest whole number. Enter either a Y or N Y to indicate EPSDT involvement N to indicate no EPSDT involvement PRIOR AUTHORIZATION NUMBER 2400 REF Prior Authorization I.D. Situational Segment Reference Identification Use the qualifier G1 to identify Prior Authorization 2400 REF01 / Number 2400 REF02 / Reference Additional ID. Enter a ten digit Prior Authorization Number, DRUG IDENTIFICATION All rights reserved Page 19

19 2410 LIN Drug Identification 2410 LIN01 / Reference Identification 2410 Reference Identification LIN02 / 2410 LIN03 / Reference Additional I.D. Situational Segment. Used to specify billing/reporting of drugs that may be part of the service entered in the SV1 segment. Reference ID Use the qualifier N4 to identify National Drug Code formatting Enter the National Drug Code. Format of this field must be DRUG QUANTITY 2410 CTP Drug Quantity Usage is Situational. To specify how units are measured CTP04 / Quantity Enter the National Drug Unit Count 2410 CTP05-1/ Unit of Measure Enter one of the following two character codes. GR =Gram ME =Milligram ML =Milliliter UN =Unit PRESCRIPTION, OR COMPOUND DRUG ASSOC NUMBER 2410 REF Prescription Number 2410 REF01 / Reference Identification 2410 REF02 / Reference Additional I.D. 2420A - RENDERING PROVIDER NAME 2420A NM1 Rendering Provider 2420A NM101 / Entity Identifier Code Enter: 82 Situational Segment... Used to specify prescription number. Use the qualifier XZ to identify Pharmacy Prescription Number Enter the prescription number. (Can be up to 50 characters long) Situational segment. To Supply the Full Name of Rendering Provider at the service line level. 2420A NM102 Entity Type Enter: 2 (for non-person entity) or 1 (for a person) 2420A NM103 / Name Last or Organization Name Can be up to 60 characters long. Enter: If an entity - (Rendering Provider Name), If a person (Enter Last Name) 2420A NM104 / Name - First Enter: (if a person) (Up to 35 characters) 2420A NM105 / Name - Middle Enter: (if a person) 2420A NM106 / Name - Prefix Enter: * 2420A NM107 / Name - Suffix Enter: * 2420A NM108 / Identification Code 2420A NM109 Identification Code If NPI follows, then enter XX here. Enter: NPI if the rendering provider is a healthcare provider. Otherwise, enter EIN or SSN here, Note1: The Rendering Provider Medicaid ID Number is 2420A - RENDERING PROVIDER SECONDARY SPECIALTY INFORMATION All rights reserved Page 20

20 2420A PRV Rendering Provider Specialty Information Optional Segment. Required when Rendering Provider shares an NPI number. When NPI number is shared, this segment is used to find the matching Medicaid I.D. 2420A PRV01 Provider Code Use the qualifier PE to indicate Rendering Provider. 2420A PRV02/ Reference Identification 2420A PRV03/ Reference Identification Use the qualifier PXC to indicate health care provider taxonomy code. Use the taxonomy code that is on file with us for Rendering Provider. This is to ensure that the claim is processed correctly when a NPI is used. 2420A - RENDERING PROVIDER SECONDARY IDENTIFICATION 2420A 2420A REF REF01 Rendering Provider Secondary Identification Reference Identification Situational Segment. Required if something other than NPI is needed to identify the rendering provider at the service line level. If used, should equal G2 Commercial Provider Number (Replaces code 1D in 4010) 2024A REF02/ Reference Identification If a health care provider, use employer s I.D. number. If an atypical provider, use 10 digit Provider I.D LINE ADJUDICATION INFORMATION (for COB) Line Adjudication Situational Segment. Required when field NM109, in Loop 2430 SVD Information ID-2330B is submitted. SVD01 / Should match one occurrence of NM109, in Loop ID Other Payer Identification 2330B, identifying the other payer 2430 SVD02 / Monetary Amount Enter Third Party Payment Amount (at the line level ONLY) Note: This is used for crossover detail paid amount. SE - TRANSACTION SET TRAILER SE SE Transaction Set Trailer Designed to transmit one or more claims per billing provider SE SE01 Transaction Segment Count Number of segments included within the ST/SE segments SE SE02 Transaction Set Control Number Must be identical to ST02, Transaction Set Header-Field2. GE - FUNCTIONAL GROUP TRAILER All rights reserved Page 21

21 GE GE Functional Group Trailer To indicate the end of a functional group and to provide control information. GE GE01 / Number of Transaction Sets Number of Transaction Sets (ST/SE) GE GE02 / Group Control Number Must be identical to GS06, Functional Group Header-Field6 IEA - INTERCHANGE CONTROL TRAILER IEA IEA Interchange Control Header - End IEA IEA01 Number of Functional IEA Groups Interchange Control IEA02 Number To end the interchange of zero or more functional groups and interchange-related control segments. Number of Functional Groups (GS/GE). Must be identical to ISA13 Can be All rights reserved Page 22

22 DISCLAIMER This document has been prepared as a CCA specific companion document to the implementation guide and will clarify when conditional data elements and segments must be used for CCA reporting. This companion guide document supplements but does not supersede any requirements in the 837 version 5010 implementation guides. All rights reserved Page 23

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