Alameda Alliance for Health

Transcription

1 Alameda Alliance for Health Standard Companion Guide Transaction Information Instructions related to Transactions based on ASC X12 Implementation Guides, version X222A1 Health Care Claims (837P) Transaction for Inbound Professional Claims\ Encounters Companion Guide Version Number: V.1.2 October 2013 October X222A1 1

2 This template is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided as is without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X Companion Guide copyright by Alameda Alliance for Health 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. October X222A1 2

3 Table of Contents 1 TI Introduction Background Overview of HIPAA Legislation Compliance according to HIPAA Compliance according to ASC X Intended Use Included ASC X12 Implementation Guides Summary of the Alliance s 837P Inbound Professional Claims/Encounters Transaction TI TI Additional Information Frequently Asked Questions EDI Enrollment/Certification Testing Provider EDI Enrollment Certification and Testing File Naming Convention... Error! Bookmark not defined. 5.4 File Attributes Delimiters Claims Requiring Attachments Connectivity / Contact information Communication Protocols/File Transmissions Transferring Files Requirements Contact: EDI Customer Service Contact: EDI Technical Assistance EDI Hours of Operations TI Change Summary October X222A1 3

4 Transaction Instruction (TI) 1 TI Introduction 1.1 Background Overview of HIPAA Legislation The Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries 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. October X222A1 4

5 Modifying any requirement contained in the implementation guide. 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 stand-alone 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. 2 Included ASC X12 Implementation Guides This table lists the X12N Implementation Guides for which specific transaction Instructions apply and which are included in Section 3 of this document. Unique ID Name X222A1 Health Care Claim: Professional (837) 3 Summary of the Alliance s 837P Inbound Professional Claims/Encounters Transaction TI The 837P inbound transaction is used to submit professional health care claims to the Alliance for adjudication and payment. In addition, the transaction can be used to submit professional health care encounters to the Alliance from delegated trading partners. The Transaction Table contains one or more rows for each segment for which a supplemental instruction is needed. The Transaction Table does not represent all of the fields necessary for a successful transaction. The TR3 should be reviewed for additional fields that are required and/or are situational and should be included if they are available in your claims/encounters system. Only those elements that the Alliance expects to see or those that required commentary are presented in the Transaction Table. Legend SHADED rows represent segments in the X12N implementation guide. NON-SHADED rows represent data elements in the X12N implementation guide. Loop ID Reference Name Codes Notes/Comments ISA Interchange Control October X222A1 5

6 Loop ID Reference Name Codes Notes/Comments ISA01 ISA03 ISA05 Authorization Information Qualifier Security Information Qualifier Interchange Id Qualifier (Sender) ISA06 Interchange Sender Id Sender or Trading Partner s Federal Tax ID ISA07 Interchange Id Qualifier (Receiver) 00 The Alliance expects to see 00 in this segment. 00 The Alliance expects to see 00 in this segment. 30 U.S. Federal Tax Identification Number Sender s or Trading Partner s Federal Tax ID 30 U.S. Federal Tax Identification Number ISA08 Interchange Receiver Id The Alliance s Federal Tax ID ISA11 Repetition Separator ^ A carat (^) is preferred by the Alliance ISA15 Usage Indicator P or T P - Production Data T - Test Data Use T during testing. ISA16 GS Component Element Separator Functional Group Header : A colon is preferred by the Alliance GS01 Functional Identifier Code HC HC Health Care Claim (837) GS02 GS03 GS08 ST ST03 BHT Application Sender's Code Application Receiver's Code Version/Release/Industry Identifier Code Transaction Set Header Implementation Convention Reference Beginning of Hierarchical Transaction Sender s or Trading Partner s Federal Tax ID Same value as ISA Same value as ISA X222A X222A1 Use current adopted version. This version number should also appear in ST03. Use current adopted version. This version number should also appear in GS08. BHT06 Transaction Type Code CH, RP For Claims - use CH Chargeable For Encounters - use RP Reporting 1000A NM1 Submitter Name 1000A NM109 Identification Code Submitter s Federal Tax ID 1000B NM1 Receiver Name 1000B NM103 Receiver Name Alameda Alliance for Health 1000B NM109 Receiver Primary Identifier 2000B HL Subscriber Hierarchical Level Submitter s Federal Tax ID Alameda Alliance for Health The Alliance s Federal Tax ID 2000B HL04 Hierarchical Child Code 0 The Alliance s members have individual member ID s; therefore, the October X222A1 6

7 Loop ID Reference Name Codes Notes/Comments 2000B SBR Subscriber Information 2000B SBR01 Payer Responsibility Sequence Number Code 2000B SBR03 Subscriber Group or Policy Number 2010BA NM1 Subscriber: Name 2010BA NM108 Subscriber: Member Id Number 2010BA NM109 Subscriber Primary Identifier 2010BB NM1 Payer Name subscriber is always the patient. Since the patient is the subscriber, no dependent levels are needed. Always use 0 in this data element and do not use Loop 2000C Patient Detail Loop P, S, T Use P for claims. Use S for encounters. Use S or T when true COB exists and include the appropriate COB loops per the IG. MCAL, ACC, IHSS, AS, ASD MI new member ID on or after 12/1/2013 Else digits no dashes Else 12 digit Member ID for AS and ASD members 2010BB NM103 Payer Name ALAMEDA ALLIANCE FOR HEALTH 2010BB NM108 Identification Code Qualifier PI Use these alpha numeric numbers to indicate line of business. MCAL MediCal, ACC Alliance Complete Care, IHSS Group Care, AS Alliance Select, ASD Alliance Select Direct. Enter MI to qualify the member s primary identifier; the member ID. The Alliance issued subscriber number (9, 11 or 12 digits) is preferred and required for encounters. Will also accept: - DHCS s CIN Number - Medi-Cal Number - Medicare HIC Number Note: The new nine digit member ID will be preferred on or after 12/1/2013 except for AS/ASD members; use 12 digit member ID ALAMEDA ALLIANCE FOR HEALTH is required for both claims and encounters. PI - Payer Identification 2010BB NM109 Payer Identifier Use the Alliance s NPI number 2300 CLM Claim Information 2300 CLM01 Patient Control Number A unique number is required CLM02 Total Claim Charge Amount Must be greater than or equal to zero and total must equal sum of al line level charges 2300 AMT Patient Amount Paid Required if patient has paid an amount toward this claim such as a co-payment 2300 REF Referral Number Required when a referral number is needed for the claim/encounter REF Prior Authorization Required when a prior authorization number is needed for the October X222A1 7

8 Loop ID Reference Name Codes Notes/Comments 2300 REF Clinical Laboratory Improvement Amendment (CLIA) Number 2300 REF Claim Identifier For Transmission Intermediaries claim/encounter to provider. Required if facility is CLIA certified and performing CLIA covered lab services. Scan document control number required for scanning/ocr-to-edi submitter. Or may by used by clearinghouse submitters for claim trace number NTE Claim Note Required for encounters to report the date the delegated entity received the encounter. Use CCYYMMDD format HI Health Care Diagnosis Code 2300 HI01- HI HI02- HI A REF Referring Provider Secondary Identification 2310A REF01- REF02 Diagnosis Type Code BK Use the BK qualifier to indicate the principal diagnosis code. Use ICD9 diagnosis codes until ICD10 diagnosis codes are adopted on October 1, 2014 Diagnosis Type Code BF Enter BF to qualify each of up to eleven (11) additional ICD9 diagnosis codes. Use ICD9 diagnosis codes until ICD10 diagnosis codes are adopted on October 1, 2014 Referring Provider Secondary Identification 2310B REF Rendering Provider Secondary Identification 2310B REF01- REF02 Rendering Provider Secondary Identification 2310C NM1 Service Facility Location Name 2320 SBR Other Subscriber Information 2320 SBR01 Payer Responsibility Sequence Number Code 0B 0B P or T State license required for providers State license required for providers Service/Rendering location segment required for all claims and encounters Required when submitting COB information SBR03 Insured Group or Policy Number 2320 AMT COB Payer Paid Amount MCAL, ACC, IHSS, AS, ASD Required for all encounters. Use P when delegated entity was primary payer or T when delegated entity had true COB with another payer. Required for all encounters; Use these alpha numeric numbers to indicate line of business. MCAL MediCal, ACC Alliance Complete Care, IHSS Group Care, AS Alliance Select, ASD Alliance Select Direct. October X222A1 8

9 Loop ID Reference Name Codes Notes/Comments 2320 AMT COB Payer Paid Amount Required for claims where there is COB and for all encounters. CMS is requiring payers paid amount as a part their Encounter Data Processing System (EDPS) OI Other Insurance Coverage Information 2320 OI03 Benefits Assignment Certification Indicator Required for claims when there is true COB and for all encounters. Must match the value in Loop 2300, CLM A NM1 Other Subscriber Name Required for claims when there is true COB and for all encounters. Must match the values in Loop 2010BA 2330B NM1 Other Payer Name Required for claims when there is true COB and for all encounters. 2330B NM109 Other Payer Primary Identifier 2330B DTP Check Or Remittance Date 2330B REF Other Payer Claim Control Number 2400 CN1 Contract Information 2400 CN101 Contract Information 02 - Per Diem, (i.e. FFS) 05 Capitated 09 - Denied 2400 NTE Line Note F8 For encounters submit the name of the delegated entity. Use the adjudicating payer s Tax ID number. For encounters, this number should match SVD01 of Loop Required for claims when there is true COB and for all encounters to report the date the claim was paid (if done at the claim level; or can report this at the line level but not both). Required for claims when there is true COB and for all encounters. This should be a unique number, not the provider s claim control number. Required for encounter lines. If 09 is reported in CN101, report denied reason in NTE Line Note. If Line is FFS, use 02; if line was capitated, use NTE02 Line Note Required for claims when there is true COB and for all encounters to report lines with a denied status. Service line denial code followed by a hyphen then the denial reason with a maximum of 80 characters LIN Drug Identification Required to report NDC code for administered office/home injectibles and immunizations. CPT code must also be reported in the SV1 segment 2410 CTP04 Drug Quantity Required to report the National Drug Unit Count 2410 CTP05 Unit or Basis for Measurement Code F2, GR, ME, ML, UN Required to report the basis for measurement. October X222A1 9

10 Loop ID Reference Name Codes Notes/Comments 2430 SVD Line Adjudication Information Required for claims when there is true COB and for all encounters to report information regarding the adjudication of the claim. SVD01 should match the value in Loop 2330B, NM109 (Other Payer s Tax ID) 2430 CAS Line Adjustment Required for encounters to report adjustments on previously submitted encounters DTP Line Check Or Remittance Date Required for claims when there is true COB and for all encounters to report the date the claim line was paid. 4 TI Additional Information 4.1 Frequently Asked Questions Q. What is the difference between a claim file and an encounter file? A. A claim file is typically submitted by an Alliance directly contracted provider for adjudication and payment by the Alliance. Encounter files are submitted by the Alliance s delegated entities and includes claims that have been previously adjudicated and paid by the delegated entity. Some of the differences in the files are: BHT06 - for claims you would report a CH for chargeable whereas for encounters you would report an RP for reportable. COB/Other Payer Segments for claims the segments associated with COB and the other payer are used only when there is true COB between the Alliance and another payer to whom the provider has submitted a claim. The Alliance is using the payer-to-payer COB model for the submission of encounters. In this model the Alliance is considered both the receiver and the payer in Loop 2010BB and the delegated entity is the other payer in Loop 2330B. In addition COB and Other Payer segments are used to report how the delegated entity adjudicated the claim. See the Technical Report Type 3 (TR3) implementation guides (IG) available for purchase from Washington Publishing Company for further information on the payer-to-payer COB model. October X222A1 10

11 5 EDI Enrollment/Certification Testing 5.1 Provider EDI Enrollment For EDI claims submitters, enrollment is required to set up your system with the Alameda Alliance claims adjudication system. Please follow the instructions and print, complete, sign and fax the EDI Trading Partner Agreement form which is located on the internet located here: ding%20partner%20agreement.pdf 5.2 Certification and Testing Testing consists of the following steps: Submitting Test Claims/Encounters Validation of the data on the claims/encounters via test data warehouse Certification of multiple files Submitting Test Claims: Providers must test their claims/files with the Alliance prior to submitting claims into the production area. Providers are required to successfully process a minimum of three consecutive files in order to move to the production mode. Receipt of 997 file acknowledgement, summary and detail reports for claim reconciliation is a part of the testing. A secure FTP account on Alameda Alliance s secure server will be provided: Test and production files should be submitted to the Alliance via secure ftp Each test file should at least claims ISA15 in each file must contain T (Test) Validation of the data on the claims: Testing includes verifying the file and claims format is included as required in ANSI X X222A1 and the Alameda Alliance Companion Guide. After the file is submitted, you will receive a File Syntax Acknowledgement (997) within 24 hours. This acknowledgment file (997) should be used to determine: 1. that the file was received and the file can be processed. October X222A1 11

12 2. If the file indicates a file error, corrective action must be taken and the file resubmitted 3. If the file is accepted, preprocessing edits will be performed and a test claims summary and test claims detail report will be provided for your analysis Certification of multiple files: The Alliance will certify test claim files that pass 100% error free. Certification to move to production requires three clean test files. These three test files containing clean claims will move to Alameda s adjudication system to create a test ERA file. This separate process could take 7-10 days since our creation process is separate from the inbound 837 claims process. The EDI department will work closely with each trading partner during this step. For 837 Claim or Encounters submissions: CAAAYYMMDD.00# or EAAAYYMMDD.00# Where: C= Claim File, E = encounter file AAA = Trading partner designation assigned by the Alliance YY= submission Year MM = Submission Month DD = Submission Day 00# = Sequence identification number, using 001 for first file submitted in a day, incrementing for each additional file submitted that day. (Example: CAAA would be the first file submitted on February 29, 2013, CAAA would be the second file submitted that day) 5.3 File Attributes Each file should only contain one type of transaction. 5.4 Delimiters The Alliance requires the following delimiters be used: DELIMITER FOR: NAME CHARACTER Data Element Separator Asterisk * Repetition Separator Carat ^ October X222A1 12

13 Component Element Separator : : Segment Terminator Tilde ~ 5.5 Claims Requiring Attachments Claims that require attachments should not be submitted electronically. 6 Connectivity / Contact information 6.1 Communication Protocols/File Transmissions Transferring Files All electronic data is transferred to and from the Alliance electronically via the Internet to the Alliance s File Secure Transfer Protocol (SFTP) server. The secure FTP server software called AAH Secure Transport Access provides a straight SFTP connection or alternatively, an HTTPS connection, which behaves like a web portal. Both step-by-step guides describing these communications methods will be provided to new EDI submitters for file submission and file (reports, ERA) retrieval Requirements All Providers are required to have the following hardware and software to send and receive data: 1. Internet access and SFTP software. 2. A PC running Windows 98, Windows XP, Vista and Windows 7 Supported sftp Configurations: Secure FTP with SSL 128bit encryption. Strong passwords are required and enforced. SSL is mandatory on both data and command channels. Explicit SSL connection is required. The following software has tested with AAHFTP server without problems: We recommend using FileZilla FTP Client. Download and Install the Free Client. ( For new EDI submitters, a secure FTP mailbox will be setup and credentials (username and password) provided to the submitters. October X222A1 13

14 6.2 Contact: EDI Customer Service Assistance with secure FTP connection to the Alliance or password changes should be referred to: The Alameda Alliance for Health Service Desk: Call: Contact: EDI Technical Assistance For questions or comments regarding this Companion Guide or other X12 related questions, please contact: Seth Masters EDI Manager Phone: EDI Hours of Operations EDI files are accepted every day, but the cutoff time daily for processing is 5pm PT Monday through Friday. If a claim file is sent after 5pm Monday through Friday, it will be considered received the next business day. Holidays, Saturdays, Sundays are not considered business days and claims are not processed on these days. 7 TI Change Summary Version Date Section(s) changed Change Summary /19/2011 Initial Release Initial Release /24/2011 Section 3 Removed repeats of ISA information p /24/2011 Section 3; ISA11 Repetition Separator /31/2011 Section 3; GS08/ST03 changed to carat ^. Made correction to version # to X222A /18/2012 Section 5.3 File Naming Convention: added new file name convention for encounters submissions /18/2013 Section 3; ISA16 Corrected; the colon is the preferred component element separator 1.2 5/18/2013 Section 3, CLM01 CLM01; patient control October X222A1 14

15 page /18/2013 Section 3, 2300; REF*X /18/2013 Section 3, 2300 HI*BH and HI*BF; Principal and other diagnosis codes. ICD-10 use timeline changed, page /18/2013 Section 3, 2320 SBR03: Group # required for encounter reporting, page /18/2013 Section 3, 2330B Other Payer Claim Control Number, page /18/2013 Section 3, 2400 CN101- Contract information, page /18/2013 Section 3, 2410 CTP04 and CTP05; Drug Qty number/claim number is required to be unique within the file CLIA # is required for CLIA lab service by CLIA certified facilities ICD-10 implementation date change to October 1, 2014 Use MCAL, ACC, IHSS, or HFP, AS, or ASD in this field so AAH will be able to determine which LOB the delegated entity used to adjudicated the original claim. For encounters; this number is required to be unique and not the provider s claim control number Emphasis placed on correct code usage for FFS and Capitated claims lines. Emphasize that this segment is required when reporting LIN segment and Measurement 1.2 5/18/2013 Section 5 Completely rewritten to clarify new connectivity and testing process /28/2013 Section 3, SBR03, page /20/2013 Section 3: 2010BA Subscriber Name, NM109 Added two new Lines of Business for those delegates assigned Covered California Exchange members: AllianceSelect (AS) and AllianceSelect Direct (ASD). Added new member ID as preferred option when new member ID s become active except for AS/ASD members; use 12 digit ID. October X222A1 15

16 Purposefully left blank. October X222A1 16