Cabinet for Health and Family Services Department for Medicaid Services

Transcription

1 KyHealth Choices 277 Health Care Payer Unsolicited Claim Status (ASC X12N 277) Companion Guide Version 2.3 Version Cabinet for Health and Family Services Department for Medicaid Services August 29, 2006

2 Document Change Log Version Changed Date Changed By Reason 1.0 7/3/2006 EDS Creation of document 1 st Draft /7/2006 EDS (Kim White) Added KyHealth Choices to the header page /22/2006 EDS (Kim White) ISA14 Changed 0 to 1 BHT03 Changed to: FFS: RA (Remittance) number Encounter: Trading Partner ID and Current Date in CCYYMMDD Format 2200D-TRN02 Changed to: FFS and Encounter (Non Pharmacy): Patient Control Number that was received on the original claim. Encounter (Pharmacy): RX Number that was received on the original claim 2.2 8/24/2006 Lori McGillan (EDS) 2200D REF02 when REF01 = 1K Updated Comments for duplicate TCN or ICN 2.3 8/29/2006 Lori McGillan (EDS) Added Section 4 with information for 2200D where REF01 = 1K 2.3 8/31/2006 DMS approved

3 Table of Contents 1 Introduction Purpose Minimum Mandated Processing Requirements Special Considerations for 277U Transactions Control Segment Definitions For Kentucky Medicaid 277u Transaction ISA - Interchange Control Header Segment IEA - Interchange Control Trailer GS Functional Group Header GE Functional Group Trailer ST Transaction Set Header SE Transaction Set Trailer Valid Delimiters for Kentucky Medicaid EDI Companion Guide For The 277u Transaction Additional Information For 2200D Where REF01 = 1K Printed: 3/9/2007 Page i

4 1 Introduction The following is intended to be a companion document to the National Electronic Data Interchange Transaction Set Implementation Guide, Health Care Payer Unsolicited Claim Status, ASC X12N 277 (003070X070), and Draft 3. This transaction is not a HIPAA covered transaction. Commonwealth of Kentucky has previously supplied fee for service providers with information on claims that have suspended for review as part of the Remittance Advice information. The authors of the HIPAA covered Transaction for the Remittance Advice (835) do not recommend including information about suspended claims from the adjudication system in the remittance advice. For financial accounting purposes, the authors recommend that the remittance advice process, which generates the 835 transaction set, only contain information pertaining to finalized claims. For that reason, the Commonwealth of Kentucky is utilizing this 277 Health Care Payer Unsolicited Claim Status to communicate pended claim information in an electronic format to fee for service providers. Commonwealth of Kentucky will also utilize this to communicate paid and denied claim information to Managed Care Organizations. Those organizations will not receive the 835 transaction for paid and denied claims. Because this transaction is not a HIPAA covered transaction at this time, this companion document provides details on all segments and elements that may be sent on this transaction from the Commonwealth of Kentucky Purpose Provide fee for service providers status information for pended claims and managed care organizations status information for paid and denied claims. The business application of the 277U will also augment the use of the Health Care Claim Status Request and Response paired transaction by providing the Internal Claim Control Numbers assigned to claims for trading partners to specifically inquire upon. Unsolicited Health Care Payer Claim Status response will be sent weekly in a batch mode for fee for service providers and daily for managed care organizations. The 277 Transaction Set can be used for other instances other than the Commonwealth of Kentucky use. It can be used as the following: Notification about health care claim(s) status, including front-end acknowledgments Request for additional information about a health care claim(s) The first two additional uses of the 277 were not included in the Transactions and Set Final Regulations. However, Commonwealth of Kentucky and EDS have selected to support the implementation guideline. Printed: 3/9/2007 Page 1

5 1.1.2 Minimum Mandated Processing Requirements The business purpose described herein is not a HIPAA mandated business purpose and thus is agreed upon between willing Trading partners. Commonwealth of Kentucky requirements follow: Information Source Identifier (KYMEDICAID for Commonwealth of Kentucky) Information Receiver Identifier (As assigned by the EDS EDI area) Service Provider Identifier (NPI ID or Medicaid Provider ID) Beneficiary Identifier (Medicaid Member ID (MAID)) Claim Dates of Service (Header and/or Detail) Header Claim Submitted Charges The claim status segment is required at the header of the claim. Therefore, a header status will always be given. Within the status segment, there are certain minimum requirements: The status data element defined in the 277 Transaction Set is a composite data structure that consists of three difference data elements. It is repeated a total of three times within the STC segment. Each status data element consists of the following three data elements: 1. Health Care Claim Status Category The overall category for where the claim currently is in processing (e.g. P2 Pending/In Process The Claim is suspended pending review). 2. Health Care Claim Status Detailed information as to the reason the claim being in the category defined in the category code (e.g. 450 Awaiting spend down determination). 3. Entity Identifier The identity of the entity from which additional information about the claim has been requested if the claim is pended for additional information (e.g. QC Patient). The status effective date is always sent within this segment at the Claim Header level. This will consist of the last date that the claim adjudicated in the system. The Action is always sent at the Claim Header level. This directs the receiver of the transaction as to what actions are required on their part. The claim header submitted charge is always sent at the Claim Header level. A Free Form Text area is available for specific messages related to the Health Care Claim Status 448. The code 448 is not currently utilized, thus STC12 will not be populated. Printed: 3/9/2007 Page 2

6 1.1.3 Special Considerations for 277U Transactions 1. Subscriber, Insured = Member in the Kentucky Medicaid Eligibility Verification System The Commonwealth of Kentucky Medicaid Eligibility Verification System does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers within each program or MCO (Managed Care Organization). 2. Provider Identification = Commonwealth of Kentucky Medicaid ID or NPI The Commonwealth of Kentucky will use the Medicaid Provider Number until the National Provider Identifier (NPI) is implemented. The implementation date for NPI is scheduled for May 23, Prior to May 23, 2007, the Medicaid Provider Number must be received within the appropriate loops within the REF segment where REF01 equals 1D on the incoming 837 transaction. If REF02, where the REF01 equals 1D is not received, the claim may not process correctly. Beginning May 23, 2007 for all health care providers, the Provider NPI, Taxonomy and Zip must be received in the appropriate loops on the incoming 837 transaction. The NPI will be sent in the NM109, where NM108 equals XX. The Taxonomy will be sent in the PRV03 and the Zip will be sent in the N403. Beginning May 23, 2007 for all non-healthcare providers where an NPI is not assigned, the claim must contain the Medicaid Provider Number within the appropriate loops within the REF segment where REF01 equals 1D on the incoming 837. If the incoming 837 contains a Medicaid Provider Number and not an NPI ID, and the Commonwealth of Kentucky has the associated NPI ID on file for the Medicaid Provider Number received, the NPI ID will be returned on the 277U transaction not the Medicaid Provider Number within the 2100C Service Provider Loop. If Commonwealth of Kentucky does not have the associated NPI ID on file, the Medicaid Provider Number will be returned. Printed: 3/9/2007 Page 3

7 2 Control Segment Definitions For Kentucky Medicaid 277u Transaction X12N EDI Control Segments ISA Interchange Control Header Segment IEA Interchange Control Trailer Segment GS Functional Group Header Segment GE Functional Group Trailer Segment ST Transaction Set Header SE Transaction Set Trailer 2.1 ISA - Interchange Control Header Segment Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record. Page Loop Segment Data Element Comments B.3 N/A ISA ISA01 - Authorization Information Qualifier B.3 N/A ISA ISA02 - Authorization Information B.4 N/A ISA ISA03 - Security Information Qualifier '00' No Authorization Information Present [space fill] '00' No Security Information Present B.4 N/A ISA ISA04 - Security Information [space fill] B.4 N/A ISA ISA05 - Interchange ID Qualifier B.4 N/A ISA ISA06 - Interchange Sender ID B.4 N/A ISA ISA07 - Interchange ID Qualifier 'ZZ' Mutually Defined KY Medicaid' Sender ID 'ZZ' Mutually Defined Printed: 3/9/2007 Page 4

8 B.5 N/A ISA ISA08 - Interchange Receiver ID ID Supplied by KY Medicaid' Receiver ID B.5 N/A ISA ISA09 - Interchange Date The date format is YYMMDD B.5 N/A ISA ISA10 - Interchange Time The time format is HHMM B.5 N/A ISA ISA11 - Interchange Control Standards Identifier B.5 N/A ISA ISA12 - Interchange Control Version Number B.5 N/A ISA ISA13 - Sequential Control Number B.6 N/A ISA ISA14 - Acknowledgment Request U Interchange Control Standards Identifier Control Version Number Interchange Unique Control Number Must be identical to the interchange trailer IEA02 1 Acknowledgement Requested B.6 N/A ISA ISA15 - Usage Indicator T - Test Data P - Production Data B.6 N/A ISA ISA16 - Component Element Separator : Component Element Separator 2.2 IEA - Interchange Control Trailer Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record. Page Loop Segment Data Element Comments B.7 N/A IEA IEA01 - Number of included Functional Groups Number of included Functional Groups Printed: 3/9/2007 Page 5

9 B.7 N/A IEA IEA02 - Interchange Control Number Must be identical to the value in ISA13 Printed: 3/9/2007 Page 6

10 2.3 GS Functional Group Header Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record. Page Loop Segment Data Element Comments B.8 N/A GS GS01 - Functional ID B.8 N/A GS GS02 - Application Sender s B.8 N/A GS GS03 - Application Receiver s HN Health Care Claim Status Notification (277) This will be equal to the value in ISA06. This will be equal to the value in ISA08. B.8 N/A GS GS04 - Date The date format is YYMMDD B.8 N/A GS GS05 Time The time format is HHMM B.9 N/A GS GS06 - Group Control Number B.9 N/A GS GS07 - Responsible Agency B.9 N/A GS GS08 - Version/Release/ Industry ID Group Control Number X Responsible Agency '003070X070' Version / Release / Industry Identifier Printed: 3/9/2007 Page 7

11 2.4 GE Functional Group Trailer Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record. Page Loop Segment Data Element Comments B.10 N/A GE GE01 Number of Transaction Sets Included B.10 N/A GE GE02 Group Control Number Number of included Transaction Sets Must be identical to the value in GS ST Transaction Set Header Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record. Page Loop Segment Data Element Comments 53 N/A ST ST01 Transaction Set Identifier 53 N/A ST ST02 Transaction Set Control Number 277 Health Care Claim Status Notification Transaction Control Number Printed: 3/9/2007 Page 8

12 2.6 SE Transaction Set Trailer Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments (including the beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the claim trailer record. Page Loop Segment Data Element Comments 313 N/A SE SE01 Number of Included Segments 313 N/A SE SE02 Transaction Set Control Number Total Number of Segments included in Transaction Set Including ST and SE. Must be identical to the value in ST Valid Delimiters for Kentucky Medicaid EDI Definition ASCII Decimal Hexadecimal Segment Separator ~ 126 7E Element Separator * 42 2A Compound Element Separator : 58 3A Printed: 3/9/2007 Page 9

13 3 Companion Guide For The 277u Transaction Page Loop Segment Data Element Comments Header 28 N/A BHT BHT01 - Hierarchical Structure 28 N/A BHT BHT02 - Transaction Set Purpose 28 N/A BHT BHT03 - Reference Identification 0010 Information Source 08 Status FFS: RA (Remittance) number Encounter: Trading Partner ID and Current Date in CCYYMMDD Format 28 N/A BHT BHT04 - Date YYMMDD Current System Date 29 N/A BHT BHT06 - Transaction Type NO Notice Information Source A HL HL01 - Hierarchical ID Number A HL HL02 - Hierarchical Parent ID Number A HL HL03 - Hierarchical Level A HL HL04 - Hierarchical Child The first HL01 value will be 1 and each HL will increment by one throughout the transaction set. 0 Hierarchical Parent ID Number 20 Information Source 1 Additional Subordinate HL Data Segment in this Hierarchical Structure Payer Name Printed: 3/9/2007 Page 10

14 A NM1 NM101 Entity Identifier A NM1 NM102 Entity Type Qualifier A NM1 NM103 Name Last or Organization Name A NM1 NM108 Identification Qualifier PR - Payer 2 Non-Person Entity KYMEDICAID PI Payor Identification A NM1 NM109 - Identification KYMEDICAID A N3 N301 - Address Information A N3 N302 - Address Information When applicable additional address information is present A N4 N401 - City Name A N4 N402 - State or Province A N4 N403 - Postal Information Receiver B HL HL01 - Hierarchical ID Number B HL HL02 - Hierarchical Parent ID Number B HL HL03 - Hierarchical Level Incremented by 1 from the previous HL segment in the Transaction Set. The value in this data element will reference the Parent HL01 at the Information Source Level. 21 Information Receiver Printed: 3/9/2007 Page 11

15 B HL HL04 - Hierarchical Child 1 Additional Subordinate HL Data Segment in this Hierarchical Structure Information Receiver Name B NM1 NM101 - Entity Identifier B NM1 NM101 - Entity Type Qualifier B NM1 NM103 - Name Last or Organization Name B NM1 NM108 - Identification Qualifier 41 - Submitter 2 - Non-Person Entity Trading partner name, as defined in database. 46 Electronic Transmitter Identification Number (ETIN) B NM1 NM109 - Identification KY Medicaid assigned EDI Trading Partner ID B N3 N301 - Address Information Trading partner address 1, as defined in database B N3 N302 - Address Information Trading partner address 2, as defined in database B N4 N401 - City Name Trading partner city, as defined in database B N4 N402 - State or Province Trading partner state, as defined in database B N4 N403 - Postal Trading partner postal code, as defined in database Provider of Service C HL HL01 - Hierarchical ID Number Incremented by 1 from the previous HL segment in the Transaction Set. Printed: 3/9/2007 Page 12

16 C HL HL02 - Hierarchical Parent ID Number C HL HL03 - Hierarchical Level C HL HL04 - Hierarchical Child The value in this data element will reference the Parent HL01 at the Information Source Level. 19 Provider of Service 1 Additional Subordinate HL Data Segment in this Hierarchical Structure Provider Information C NM1 NM101 - Entity Identifier C NM1 NM102 - Entity Type Qualifier C NM1 NM103 - Name Last or Organization Name 1P Provider 1 Person 2 Non-Person Entity When NM102 = 2, Payto-Provider Organization Name as stored on KY Medicaid Provider File When NM102 = 1, Payto-Provider Last Name as stored on KY Medicaid Provider File C NM1 NM104 - Name First When NM102 = 1, Payto-Provider First Name as stored on KY Medicaid Provider File C NM1 NM108 - Identification Qualifier SV Service Provider Number XX - National Provider Identifier (NPI) Printed: 3/9/2007 Page 13

17 C NM1 NM109 - Identification 10 digit NPI assigned to the provider when qualifier equals XX. Subscriber or Assigned Kentucky Medicaid Provider Number when qualifier equals SV D HL HL01 - Hierarchical ID Number D HL HL02 - Hierarchical Parent ID Number D HL HL03 - Hierarchical Level D HL HL04 - Hierarchical Child Incremented by 1 from the previous HL segment in the Transaction Set. The value in this data element will reference the Parent HL01 at the Information Source Level. 22 Subscriber 0 No Subordinate HL Segment in this Hierarchical Structure Subscriber Name D NM1 NM101 - Entity Identifier D NM1 NM102 - Entity Type Qualifier D NM1 NM103 - Name Last or Organization Name QC - Patient 1 - Person Member s Last Name D NM1 NM104 - Name First Member s First Name D NM1 NM105 - Name Middle Member s Middle Initial, if available Printed: 3/9/2007 Page 14

18 D NM1 NM108 - Identification Qualifier MR Medicaid Recipient Identification Number D NM1 NM109 - Identification 10 digit KY MAID number Claim Submitter s Identifier D TRN TRN01 - Trace Type 2 Reference Transaction Trace Numbers D TRN TRN02 - Reference Identification FFS and Encounter (Non Pharmacy): Patient Control Number that was received on the original claim. Encounter (Pharmacy): RX Number that was received on the original claim D TRN TRN04 - Reference Identification D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier D STC STC02 - Status Information Effective Date If applicable, the value that was received on the original claim from SBR09. From List 507 Health Care Claim Status Category. From List 508 Health Care Claim Status Used to clarify STC01-2. Status Date of Claim. Format YYMMDD D STC STC03 - Action NA No Action Required D STC STC04 - Monetary Amount Total Billed Amount that was received on original claim. Printed: 3/9/2007 Page 15

19 D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier D REF REF01 - Reference Identification Qualifier D REF REF02 - Reference Identification Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 1K Payor s Claim Number First 13 positions are Internal Control Number Assigned by KY Medicaid for this claim (Internal Control Number = ICN - Previously called Transaction Control Number (TCN)) For MCOs: This data element can contain an additional 13 or 17 position duplicate ICN or duplicate TCN. See Section 4 for additional information Printed: 3/9/2007 Page 16

20 D REF REF01 - Reference Identification Qualifier D REF REF02 - Reference Identification D REF REF01 - Reference Identification Qualifier D REF REF02 - Reference Identification BLT Billing Type This REF segment is only sent if the original claim was billed on an 837I transaction for EDI or UB92 or UB04 for Paper Claims. Type of Bill that was present on the original claim EA Medical Record Identification Number Medical Record Number that was received on the original claim D DTP DTP01 - Date/Time Qualifier Service D DTP DTP02 - Date Time Period Format Qualifier RD8 Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD D DTP DTP03 - Date Time Period The Date(s) associated with this claim for Header level information. The system will take the Earliest From Date and the Latest To Date and report that information. Service Line Information Printed: 3/9/2007 Page 17

21 D SVC SVC Product/Service ID Qualifier ND = National Drug AD = American Dental Associates NU = National Health Related Item HC = Health Care Financing Administration Common Procedural Coding System D SVC SVC Product/Service ID D SVC SVC Procedure Modifier D SVC SVC Procedure Modifier D SVC SVC Procedure Modifier D SVC SVC Procedure Modifier 4 Original submitted or final adjudicated service code. Original submitted or final adjudicated service code. Original submitted or final adjudicated service code. Original submitted or final adjudicated service code. Original submitted or final adjudicated service code D SVC SVC02 - Monetary Amount Line item charge amount if available from original claim D SVC SVC03 - Monetary Amount Always equal to 0 (zero) D SVC SVC04 - Product/Service ID When both a HCPCS code and a NUBC Revenue code are associated with a line item, this data element will contain the Revenue D SVC SVC07 - Quantity Original Units of Service Submitted on Claim Printed: 3/9/2007 Page 18

22 D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier From List 507 Health Care Claim Status Category. From List 508 Health Care Claim Status Used to clarify STC D STC STC04 - Monetary Amount Detail Billed Amount that was received on original claim D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier D STC STC Health Care Claim Status Category D STC STC Health Care Claim Status D STC STC Entity Identifier D REF REF01 - Reference Identification Qualifier Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 Used to further clarify STC01-1 through STC01-3 FJ Line Item Control Number Printed: 3/9/2007 Page 19

23 D REF REF02 - Reference Identification Value that was submitted on the original claim if submitted on the 837I, 837P or 837D transaction. When value is not available from original submitted claim, a sequential number is assigned to each line of the claim starting with 1 and incrementing by D DTP DTP01 - Date/Time Qualifier Service D DTP DTP02 - Date Time Period Format Qualifier RD8 Range of Dates Expressed in Format CCYYMMDD- CCYYMMDD D DTP DTP03 - Date Time Period Only used when a Service line date is available on the claim. If only a From Date is available, the "From Date" will equal the To Date. Printed: 3/9/2007 Page 20

24 4 Additional Information For 2200D Where REF01 = 1K The value in 2200D REF02, where REF01 equals 1K, is determined as follows. The first 13 positions for a Fee For Service or an Encounter contain the Internal Control Number assigned by KY Medicaid for this claim. The Internal Control Number (ICN) was previously called Transaction Control Number (TCN). For MCO encounters, the next 13 or 17 positions could contain a duplicate ICN or duplicate TCN. Examples: REF*1K* In this example, is the ICN. REF*1K* In this example, is the ICN and is a duplicate ICN. REF*1K* In this example, is the ICN and is a duplicate TCN. Printed: 3/9/2007 Page 21