X A1 Addenda Companion Document - Institutional (004010X096A1) - EFFECTIVE 05/23/07

Transcription

1 Companion Document 837I++ X A1 Addenda Companion Document - Institutional (004010X096A1) - EFFECTIVE 05/23/07 Introduction The Federal Department of Health and Human Services has adopted regulations, under the Health Insurance Portability and Accountability Act (HIPAA), that establish minimum standards for certain electronic transactions conducted among health plans, clearinghouses and certain health care providers ( covered entities ). These rules were scheduled to go into effect October 16, However, most covered entities, including Empire BlueCross BlueShield, obtained a one-year extension. Empire BlueCross BlueShield will be compliant by October 16, Health care plans are required by law to have the ability to send and receive HIPAA compliant transactions. Effective October 16, 2003 only the X version 4010A1 identifi ed under HIPAA will be supported for electronic claim transactions. The HIPAA implementation guides provide assistance in developing and executing the electronic transfer of health care data. The implementation guides can be downloaded from the Washington Publishing Company website at The A1 (004010X096A1) implementation guide should be used for claim submission if you are currently submitting claims on the UB-92 electronic format. Based on the A1 (004010X096A1) implementation guide there are specifi c Empire business requirements that must be further clarifi ed so entities can do business with Empire. This document will identify Empire specifi c requirements for the A1 (004010X096A1) implementation guide using available data within the implementation guide. Update May 2007 As set forth by the Centers for Medicare & Medicaid Service (CMS), Empire is implementing a contingency period beginning May 23, 2007 through January 25, During this contingency period, in order to prevent claims from rejecting, 1) submit BOTH registered NPI and EPIN (Empire recommended), 2) submit with registered NPI only, or 3) continue submitting EPIN only as done currently. Refer to Loop 2010AA Billing Provider section of this document for details. On and after January 26, 2008, the NPI replaces the EPIN assigned by Empire. Validation of the Federal Tax ID number/social Security Number will be done against internal fi les to ensure matching to the NPI submitted. Claims will fail if 1) EPIN is submitted, 2) both NPI and EPIN are present, and 3) Federal Tax ID number/social Security Number is invalid or does not match our internal fi les for the NPI that was submitted. *Note - EPIN is accepted for those providers not required to have an NPI. Page 1 of 16 Release 2 (050107) Version A1 - Oct 2002

2 General Instructions Electronic Media Claims (EMC) bulletins will be issued documenting the front-end edits, the use of the 997 Acknowledgement and the new EMC receipt report. Report Printing: A new front-end receipt report has been developed for 837 version 4010A1 transactions. The report will provide a status of each ISA through IEA. The new report number is EMCD R01 for production transmissions and EMCD6110-R11 for new biller transmissions. The report must be printed landscape. Item 1 There are many notes in the implementation guide that require data based on an inpatient or outpatient claim. The implementation guide does not define inpatient and outpatient. Empire determines the claim type based on the type of bill. 2 Character Sets Supported by Empire 3 Multiple ISA through IEA s in a file with different Receiver ID s (ISA08). Empire BCBS Requirement Empire definition of Institutional Claim Types: Inpatient Type of Bill: 11X, 12X, 17X, 18X, 21X, 22X, 27X, 28X, 81X, 82X Note: 81X and 82X will only be referenced as inpatient when revenue code 655, 656 or 658 is present. Outpatient Type of Bill: 13X,14X, 23X, 33X, 34X, 71X, 72X, 73X, 74X, 75X, 76X, 83X Home Health Type of Bill: 33X and 34X Hospice Type of Bill: 81X, and 82X Note: Note: 81X and 82X will only be referenced as hospice when revenue code 655, 656 or 658 is not present. Empire will support all values identified in the Basic and Extended Character Set documented in Appendix A of the A1 implementation guide. The Extended Character Set includes lower case (a.z). Lower case alpha values are not allowed in fields with an ID attribute. They must be submitted in upper case as specified in the implementation guide. For example: BHT06 must equal CH and not ch. Empire will accept multiple ISA through IEA s in a file if the receiver types are for the same Receiver ID (ISA08). If file contains multiple ISA through IEA s, receiver ID in ISA08 must all be the same. All ISA through IEA s with a value in ISA08 equal to the 'ISA08 value in the first ISA segment' will process. All ISA through IEA s with a value in ISA08 not equal to the 'ISA08 value in the first ISA segment' will NOT be processed. 4 Mixed Transaction Sets Empire will only accept multiple transactions of the same type within a single transmission (ISA through IEA). For example, multiple 837 transactions. Empire will not support a single transmission containing different transactions such as an 837 (claim), 270 (eligibility request) and 276 (claim status request). Empire will not accept the 275 transaction until it becomes a HIPAA standard. Attachment data should be communicated through fax, mail or . Alcohol-Substance Abuse attachment data can be submitted electronically in the UB-92 specification. The A1 does not support this function. Attachment data should be communicated through fax, mail or . 5 Combined Claim Submissions This document only addresses claims for processing by Empire Blue Cross Blue Shield. Refer to the Institutional Quicklink Companion Document for details on submitting commercial claims. 6 Subscriber ID Format Refer to the Detail Transaction Instruction section of this document for submission format. The front-end edit documentation will contain complete edit requirements on the subscriber ID. 7 Subscriber and Patient Last Must be Alpha and may contain one embedded space and/or hyphen. and First Name Formats 8 Subscriber and patient Must equal A-Z or blank. name middle initial format Page 2 of 16 Release 2 Version A1 - Oct 2002

3 Item Empire BCBS Requirement 9 Field Size Limitations External Sources External code sources can limit the field size from what is defined in the implementation guide. If the IG allows for 30 positions and the external code source defines 2 positions, the valid field size would be a maximum of two positions. Example: For Condition s, the IG allows for 30 positions. Since the Condition codes are defined by NUBC as 2 positions, the field size is reduced to 2 positions. 10 X Acknowledgment Transaction Data Element 782 Refer to Appendix A in the X096A1 implementation guide. Data element 782 is limited to a maximum length of 10 characters including reported or implied places for cents. An X Acknowledgment Transaction will be created for every claim functional group, GS through GE (GS01 equal to HC) submitted to Empire. 11 TA1 Interchange Acknowledgement The 997 reports accepted and rejected transactions (ST through SE) at the X12 standard level. Standard level errors are reported on rejected transactions. It is imperative that claim submitters retrieve and process the 997 transaction. Additional information on the 997 will be documented separately. As the 837 transaction is processed through our translator, a TA1 acknowledgment will be produced if there are any errors in the ISA and GS segments. The TA1 acknowledgement will not be sent to the submitter of the 837. The errors received will be reported on the Empire Receipt Report under the Transmission Summary section of the report. The error numbers match what would be reported in the TA105 element within the TA1 segment. Refer to section B.12, data element TA105 for a listing of the error numbers and narratives. 12 Front End Validation The levels of editing performed in the front-end system will be documented separately. 13 Negative s in R defined fields. Data Element types defined in the implementation guide as R allow negative or positive values to be submitted. The front-end edit documentation will contain specific fields where negative values are not allowed. For these specific fields, if a leading minus (-) sign is present, the claim will be returned with an Empire business edit. 14 Service Line Charge Amounts Empire requires at least one service line other than the 0001 revenue code with a dollar amount greater than zero. 15 Revenue s The National Uniform Billing Committee (NUBC) defines revenue codes as a 4 position numeric field. The leading zero is a significant value and must be present. Examples: 0360 is a valid code submitted in 2400, SV is an invalid code submitted in 2400, SV Service Line Units This data element is defined as an R value and decimals are allowed per the HIPAA implementation guide. For service line units, Empire will only accept whole units. As an example 1.0 would be allowed. If 1.5 is present, the claim will be returned with a business edit. 17 Group Number Format Refer to the Detail Transaction Instruction section of this document for group number format. The front-end edit documentation will contain complete edit requirements on the group number. Page 3 of 16 Release 2 Version A1 - Oct 2002

4 Item Empire BCBS Requirement 17 Group Number Format Refer to the Detail Transaction Instruction section of this document for group number format. The front-end edit documentation will contain complete edit requirements on the group number. 18 Submission of Electronic Adjustments 19 Billing Provider and Federal Tax ID Number Update May 2007 Prepare for submitting NPI only effective 5/23/07 during contingency period through 1/25/08 20 Subscriber and Patient Loops The A1 allows for the electronic submission of adjustments to previously processed claims. Empire will apply certain business edits to insure we can facilitate the processing of electronic adjustments. We will accept valid 837 adjustments on all previously adjudicated claims regardless of the claim format used to submit the original claim. Fields required for submission of electronic adjustments: 2300 CLM05-3 equal to 7 or REF (REF01 equal to F8 ) 2300 REF (REF02 equal to Original Reference Number) 2300 NTE (NTE01 = ADD) 2300 NTE required when HI value equal to D HI (HI value equal to D0-D9 or E0) Adjusted claims will go through the same level of editing as original claims. The claim adjustment must contain the data that is being changed from the original claim. The front-end edit documentation also contains specific edit requirements for submission of electronic adjustments. Empire will process all claims which contain a valid Blue Cross Number supplied as the Billing Provider identified in the Loop 2010AA REF segment. Beginning February 10, 2006, Empire will allow the submission of the National Provider Identifier (NPI) IN ADDITION to the Empire assigned provider number (EPIN). If 1) the NPI is submitted on 837 claims, the EPIN MUST continue to be submitted in REF02 of Loop 2010AA, and 2) the NPI is submitted in the Billing Provider Loop, the billing provider Federal Tax Identification Number must be submitted in the 2010AA Billing Provider REF segment in addition to a REF segment for the Empire EPIN number. The Federal Tax Identification number will not be edited for validity at this time but will be at a later date. For those providers who have an NPI, beginning May 23, 2007, Empire will accommodate different methods of claim submission by: 1) accepting claims submitted with the NPI in Loop 2010AA and Federal Tax ID in Loop 2010AA REF02. Validation of the Federal Tax ID No. will be done against an internal file to ensure matching to the NPI submitted. 2) accepting claims submitted with EPIN in Loop 2010AA REF02 and Federal Tax ID in Loop 2010AA. Only registered NPIs are subject to validation against NPI. However, for nonregistered NPIs, the EPIN must be submitted. Validation will be done by matching Tax ID against the submitted EPIN. Please refer to Loop 2010AA in the detail section of this document for reference to new contingency period through January 25, The Pay-to-Provider in Loop 2010AB and the Service Facility Provider in Loop 2310E can be submitted, however, they will not be used for processing of claims. Refer to the implementation guide for submission of claims when the subscriber and patient are the same and when the subscriber and patient are different. Page 4 of 16 Release 2 Version A1 - Oct 2002

5 Item 21 Delimiters 22 Empire Payer ID Format 23 Hierarchical Level Data Structure Empire BCBS Requirement Empire recommends using the delimiters defined in section A Character Name Delimiter * Asterisk Data Element Separator : Colon Sub-Element Separator ~ Tilde Segment Terminator Use of other characters can be discussed during the testing period with trading partners. When Empire is identified as the payer, the format of the payer code must equal: The first two positions of the Payer ID must equal 00 followed by 300 or 303. Example, or For non-empire subscribers, the first two positions of the Payer ID must equal 00 followed by the Plan on the subscriber s ID card. Please refer to section(s) , 2.3.2, and of the 837 Institutional Implementation Guide for definition of the Hierarchical Level Data Structure and the use of the HL segments. Examples of the correct 837 HL structure are included. BHT01 of the 837 (004010X096A1) defines the hierarchical structure as Information Source, Subscriber, Dependent. The information source in this implementation guide is the Billing Provider. The implementation guide shows the subscribers nested under the specific provider and the dependents nested under the specific subscriber. Empire requires that all subscribers be sent under the previous provider HL and not sent under a different provider HL and using the parent ID number to associate the subscriber to the appropriate provider. Empire requires that all dependents be sent under the previous subscriber HL and not sent under a different subscriber HL and using the parent ID number to associate the dependent to the appropriate subscriber. There will be critical HL edits in place to fail the entire transaction if the subscriber and dependent hierarchical Parent ID Number (HL02) does not match to the previous provider or subscriber HL ID Number (HL01). See edits IG0103 and IG0104 below for a description. HL01 (Hierarchical ID Number) must begin with one and increment by one for each HL segment within a ST through SE. This number uniquely identifies the HL. It is also used to associate children to the specific HL s through out the ST through SE. HL02 is used to identify the Hierarchical Parent ID Number. The information source does not use this field since this is the highest level and the information source is the parent. The subscriber and dependent HL s are children to either the information source or the subscriber and use this element to identify the what parent HL they are subordinate to. HL critical implementation guide edits applied to the HL segments include the following: (see next page ) Page 5 of 16 Release 2 Version A1 - Oct 2002

6 Item Empire BCBS Requirement Performed 1st: Processing stops if this IG edit is received. No additional IG editing performed. IG0002 Critical Error, HL01 Must Increment by 1 within the ST through SE Performed 2nd: Processing stops if these two IG edits are received. No additional IG editing performed. IG0000 Critical Error, HL03 Missing/INV, Further Editing Not Performed IG0059 Critical Error, 1st HL03 Not = 20 or 2nd Not = 22 Performed 3rd: Processing stops if this IG edit is received. No additional IG editing performed. IG0103 Subscriber HL parent ID must = the previous provider HL ID Performed 4th: Processing stops if this IG edit is received. No additional IG editing performed. IG0104 Dependent HL parent ID must = the previous subscriber HL ID Performed 5th: Processing stops if this IG edit is received. No additional IG editing performed. IG0106 Subscriber Hl Missing, Required when Loop 2300 is Present If any of the above edits are received, processing will stop. The errors must be corrected and the entire ST through SE must be resubmitted. Please refer to the validation documentation for additional information on these edits. If none of the above critical errors are received, all IG edits will be performed on all segments within the ST through SE. 24 Use of Procedure s Use of procedure codes is not allowed on outpatient claims. Outpatient claims are defined above. All outpatient claims that contain a HI segment with qualifiers equal to Updated March 2004 BR or BQ will fail with an implementation guide edit. This requirement was documented in the Federal Register as part of the Transaction and Set final rule. 25 Baby Birth Weight In version 4010, the baby birth weight was identified in Loop 2000B or 2000C PAT08. The PAT segment is not used in version 4010A1. In version 4010A1, the baby birth weight is determined from Loop 2300 HI segment (HI equal to BE) code equal to R decimal Data Elements (Monetary Amounts) Please refer to section A in the 837 Implementation Guide for instructions on how to submit decimal data elements (Monetary Amounts). Updated March 2004 Submission of R Decimal Data (Monetary Amounts) must be formatted properly or the claim may suspend or process incorrectly. 27 Transmission File Size Example: If you are submitting $300.00, populate the element as follows: CLM*123ABC*300* (Note: the 300 represents CLM02) If you populate the element with (CLM*123ABC*30000*), you are actually submitting 30, If you make this error, it will cause your claim to suspend or pay incorrectly. If the dollar amount you are submitting contains cents (300.12), you must include the decimal. CLM*123ABC*300.12* If you populate the element with (CLM*123ABC*30012*), you are actually submitting 30, If you make this error, it will cause your claim to suspend or pay incorrectly. Empire recommends sending no more than 5,000 claims per transmission. Updated March 2004 Page 6 of 16 Release 2 Version A1 - Oct 2002

7 Detail Transaction Instructions This section of the document will follow the format of the implementation guide and list specifi c requirements by segment and element. We are only documenting areas in the implementation guide where there are situational segments and elements or specifi c qualifi ers within elements that Empire requires to conduct it s business. In other cases, the implementation guide should be followed. Anywhere within our documentation where valid values are identifi ed with a single quote, the quotes are not part of the valid value. Segment Reference 837 Institutional Health Care Claim Interchange Control Header (ISA) ISA Interchange Control Header ISA05 Interchange ID ISA06 Interchange Sender ID ZZ (Submitter ID) ZZ - Mutually Defined Must equal the Empire assigned Submitter ID number. Your Submitter ID number is used as your Trading Partner ID for Empire and is validated against internal control files. Note: this will be the same value as currently reported in the UB-92, Record Type 01, Field 2, Positions The UB-92 is defined as 9(10) and is right justified and zero filled since the submitter ID is nine positions. Do not zero fill ISA06. The ISA06 value must only contain the nine position submitter ID or your file will reject for not authorized when edited against internal authorization files. ISA07 Interchange ID ISA08 Interchange Receiver ID ISA09 Interchange Date ISA12 Interchange Control Version Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ZZ ZZ - Mutually Defined If your transmission contains multiple ISA through IEAs, the value in all ISA08 elements must be equal. (YYMMDD) The Interchange Date must be present in ISA09 and must be in the YYMMDD format. The date must be equal to or less than the current date. Dates prior to the year 2000 and future dates are not allowed Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October Empire will not produce a TA1 Acknowledgment, however TA1 error messages will be reported on the EMC receipt report. ISA errors will be reported on the EMC receipt report. P, T Valid values are P or T. A submitter must be authorized to submit claims to Empire. The submitter s claims must pass the test (T) phase before production (P) claim submission is allowed. Once approved for production claims, test files can be submitted at any time. Page 7 of 16 Release 2 Version A1 - Oct 2002

8 Segment Reference 837 Institutional Health Care Claim Functional Group Header (GS) GS Functional Group Header GS02 Application Sender's GS03 Application Receiver's GS04 Date GS05 Time GS06 Group Control Number (Submitter ID) Empire does not edit this element. The value submitted must meet the implementation guide attributes Empire Blue Cross claims (CCYYMMDD) (HHMM) (Assigned by Sender) The Functional Group Creation Date must be present in GS04 and must be in CCYYMMDD format. The date must be equal to or less than the current date. Dates prior to the year 2000 and future dates are not allowed. must be a valid time in HHMM format. The X12 document, X12.6 Control Structure, section states the GS06 and GE02 shall by themselves be unique within a reasonably extended time frame whose boundaries shall be defined by trading partner agreement. GS08 Version / Release / Industry Identifier X096A1 Empire requires the GS and GE control number to be unique within the ISA through IEA. The GS06 and GE02 control numbers must equal. Operationally used to identify the 837 Institutional Health Care Claim transaction Beginning of Hierarchical Transaction P.57 BHT BHT02 Beginning of Transaction Set Hierarchical Purpose Transaction BHT06 Transaction Type P.60 REF Transmission Type Identification 837 Institutional Health Care Claim Header REF02 Loop ID 1000B Receiver Name P.67 NM1 Receiver Name CH (Transmission Type ) (Receiver Primary Identifier) Must equal 00 or 18. Empire will accept both values. Empire BCBS recognizes all submissions as chargeable. Must equal X096A1. This transaction is being used in a production mode. To indicate if a transmission is test or production, use ISA15. We recommend using the same value that submitted in GS03. Page 8 of 16 Release 2 Version A1 - Oct 2002

9 Loop ID 2010AA Billing Provider Name P.76 NM1 Billing Provider NM108 Identification 24 XX Name Identification REF REF01 Billing Reference Provider Identification Secondary Identification 837 Institutional Health Care Claim Detail Billing/Pay-to Provider Hierarchical Level (Billing Provider Primary ID) 1A EI NPI Contingency Period Updated May 2007*: Under CMS guidance, Empire is implementing a contingency period from May 23, 2007 through January 25, During this contingency period, in order to prevent claims from rejecting, 1) submit BOTH registered NPI and EPIN (Empire recommended), 2) submit with registered NPI only, or 3) continue submitting EPIN only as done currently. P.82 REF02 Reference Identification (Billing Provider Additional Identifier) 24 - Employer's Identification Number XX - HCFA National Provider Identifier EIN and registered NPI will be validated against the Empire Corporate Provider File. If NPI present, then Employee's ID No. must be present in REF segment. 1A - BC Provider Number; qualifier accompanies the EPIN in REF02 EI - Employer's ID Number; qualifier accompanies the tax ID associated with the Billing Provider NPI. 'EI' Required when NM108 = 'XX' When REF01 is '1A', this value must equal the 6 digit Empire assigned BC provider number which is used for provider authorization. The front-end edit documentation will contain complete edit requirements for the Empire BC provider number. When REF01 is 'EI', this value must equal the billing provider Federal Tax ID No. that will be validated against internal files to ensure matching with submitted NPI. Page 9 of 16 Release 2 Version A1 - Oct 2002

10 Loop ID 2000B Subscriber Hierarchical Level P.101 SBR Subscriber Information 837 Institutional Health Care Claim Detail Subscriber Hierarchical Level SBR01 Payer Responsibility Sequence Number SBR03 Reference Identification P, S, T (Insured Group or Policy Number) If the value in Loop 2000B SBR01 equals T, there must be at least two repeats of Loop 2320 equal to P and equal to S. If the value in Loop 2000B SBR01-1 equals S, there must be at least one occurrence of Loop 2320 equal to P. The implementation guide defines this element as an alphanumeric field with a minimum size of 1 and a maximum size of 30. Refer to section A in the implementation guide for submission of STRING data elements. AN attributes are string data elements. All Empire group numbers are numeric. A prefix (G, GC, YLG or any other prefix) should not be entered as part of the group number. If the subscriber ID prefix is equal to YLG, G or GC : The group number must be present and left justified Must not contain leading spaces Positions 1-4 are significant values. Example: if your group number is 11, a valid SBR segment would appear as: SBR*P*18*11******BL~ An invalid segment would appear as: SBR*P*18*011******BL~ SBR*P*18*8011******BL~ Note: If the group number on the subscriber s ID card is 5 digits, beginning with the number 8, disregard and do not enter the number 8. SBR09 BL Claim Filing Indicator BL - Blue Cross/Blue Shield Page 10 of 16 Release 2 Version A1 - Oct 2002

11 837 Institutional Health Care Claim Detail Subscriber Hierarchical Level Loop ID 2010BA Subscriber Name P.108 NM1 NM102 1 Subscriber Entity Type Name NM108 MI (Subscriber Primary Identifier) 1 - Person MI - Member Identification Number Submit the subscriber identification number as shown on Blue Cross ID Card without the suffix or the dependent number. The value entered: Must be left justified Must not contain leading spaces Must not contain all alpha characters Must not contain embedded spaces or special characters Subscriber ID body must begin immediately following the alpha prefix. No space after prefix. The ID body must not contain all 1 s, 2 s, 3 s, 4 s, 5 s, 6 s, 7 s, 8 s, 9 s, 0 s, , or literals equal to UNKNOWN, UNK, INDIVIDUAL, SELF, NONE. Must not contain low values The front-end edit document will contain complete requirements for submission of the Subscriber Primary ID. Loop ID 2010BC Payer Name P.126 NM1 NM108 Subscriber Information PI (Primary Payor ID) PI - Payor Identification For Empire subscribers: The plan code must equal or For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. Page 11 of 16 Release 2 Version A1 - Oct 2002

12 Loop ID 2010CA Patient Name P.145 NM1 Patient Name 837 Institutional Health Care Claim Detail Patient Hierarchical Level NM108 Identifcation MI (Patient Primary Identifier) MI - Member Identification Number Same requirements apply to the Subscriber and Patient Primary Identifiers. Must equal the Empire assigned subscriber identification number as shown on Blue Cross ID Card. Do not enter the suffix or the dependent number. Refer to section A in the implementation guide for submission of STRING data elements. AN attributes are string data elements. The value must be 1) left justified, 2) not contain leading spaces, 3) not contain all alpha characters, 4) not contain embedded spaces or special characters No space after prefix; Patient ID body must begin immediately following the alpha prefix. The ID body must not contain all 1 s, 2 s, 3 s, 4 s, 5 s, 6 s, 7 s, 8 s, 9 s, 0 s, , or literals equal to UNKNOWN, UNK, INDIVIDUAL, SELF, NONE. Must not contain low values Loop ID 2300 Claim Information Empire recommends sending no more than 5,000 claims per transmission. P.157 CLM CLM01 (Patient Control Empire will only store up to 20 positions for a patient Claim Claim Submitter's Number) control number as noted in the implementation Information Identifier guide. CLM02 Monetary Amount CLM05-1 Facility (Total Claim Charge Amount) (Facility Type ) Total claim charge amount must equal the sum of the service line total charges (Loop 2400, SV201, SV203). If revenue code 0001 is present, the 0001 amount must equal the sum of the service line total charges. If equal to 33 or 34, then the CL103 (patient status code) must be present. Empire requires this element for the following outpatient type of bills: 33X and 34X. The implementation guide requires this element for inpatient type of bills, it does not prohibit using this element on outpatient type of bills. Page 12 of 16 Release 2 Version A1 - Oct 2002

13 Loop ID 2300 Claim Information (cont'd) P.157 CLM Claim Information CLM05-3 Claim Frequency Type (Third Position of Uniform Billing Claim Form Bill Type) If equal to 7 (adjustment) or 8 (void) with the HI0X-1 segment qualifier BG (condition) and HI0X-2 condition code 'D9', then Loop 2300 NTE01 'ADD' and NTE02 data elements required. First three positions of NTE02 must be populated to identify the reason for the claim adjustment with values listed under NTE. HI and NTE segments accompany when CLM05-3 is '7' (adjustment) or '8' (void) P.295 Condition BG BG - Condition D9 - Condition Information HI0X-1 HI0X-1 'BG' supports the NUBC condition codes. D9 Condition codes D0-D9 and E0 support the reasons for claim adjustments and must be used HI0X-2 if the adjustment reason can be defined using one of the standard codes. P.203 Billing Note NTE01 NTE02 CLM18 Yes/No Condition or Response P.173 PWK PWK01 Claim Report Type Supplemental Information 837 Institutional Health Care Claim Detail Patient Hierarchical Level DIA POS UNT MDF DEP SOA MED AUT TFD CDR OTH (Explanation of Benefits Indicator) (Attachment Report Type ) DIA Diagnosis; POS Place of Service; UNT Units of Service; MDF Modifier; DEP Dependent Number Change; SOA Questioning Schedule of Allowance; MED Medical Necessity Appeal; AUT Authorization on File Appeal Denial; TFD Timely Filing Denial Appeals; CDR Contractual Denial Review; OTH Other N - No; Y- Yes Regardless of the value submitted in this element, Empire will continue to create a paper voucher until further notice. The following values will be reviewed for both Home Health and Alcohol/Substance Abuse Claims: AS Admission Summary B3 Physician Order CT Certification* DG Diagnostic Report DS Discharge Summary EB Explanation of Benefits NN Nursing Notes OZ Support Data for Claim RT Report of tests and Report Analysis PZ Physical Therapy Certification** PN Physical Therapy Notes*** RR Radiology Films*** *Use when submitting the American Express Authorization Number **Applicable to Home Health Claims only ***Applicable to Alcohol/Substance Abuse Claims only Page 13 of 16 Release 2 Version A1 - Oct 2002

14 Loop ID 2300 Claim Information (cont'd) P.173 PWK Claim Supplemental Information 837 Institutional Health Care Claim Detail Patient Hierarchical Level PWK02 Report Transmission AA BM EM FX *AA - Available on Request at Provider Site BM - By Mail EM - FX - By Fax P.185 REF Original Reference Number (ICN/DCN) P.200 NTE Claim Note P.203 NTE Billing Note PWK05 ID PWK06 Identification PWK07 Description REF02 Reference Identification AC (Attachment Control Number) (Attachment Description) (Claim Original Reference Number) *Use when submitting the American Express Authorization Number AC - Attachment Control Number *Use when submitting the American Express Authorization Number For the American Express Authorization Number, the value is a 6 digit alpha numeric value. Do not zero fill this element. This is not the American Express Credit Card Number. Do not send the credit card number to A total of 800 bytes of data can be submitted; maximum of 80 bytes per data allowed per Attachment Report Type and maximum of 10 PWK segments submitted. If more than 10 PWK segments are present, the claim will fail with an implementation guide edit. REF segment with a F8 qualifier is required when submitting electronic claim adjustments (CLM05-3 equal to '7' adjustment or '8' void). REF02 must be a minimum of 10 positions. When CRC01= 77 and CRC03-CRC07 = MC, Claim Note must be present. NTE01 UPI UPI - Updated Information Note Reference NTE02 Description (Claim Note Text) Must be greater than spaces When HI0X-1= 'BG', HI0X-2 = 'D9', and CLM05-3 = '7' or '8', Billing Note must be present. NTE01 ADD ADD - Additional Information Note Reference NTE02 Description (Billing Note Text) The 837 supports electronic submission of adjustments to previously processed claims. Empire will apply certain business edits to facilitate the processing of adjustment transactions. Page 14 of 16 Release 2 Version A1 - Oct 2002

15 Loop ID 2300 Claim Information (cont'd) P.205 CR6 CR610 Home Health Product/Service Care ID Information CR611 Medical P.234 HI HI01-1 Principal, Admitting, E- and Patient Reason For Visit Diagnosis Information P.248 HI Principal Procedure Information P.250 HI Other Procedure Information 837 Institutional Health Care Claim Detail Patient Hierarchical Level List HI01-2 Industry HI01-1 List HI01-1 List Principal Procedure (BR) Other Procedure (BQ) (Product or Service ID ) (Surgical Procedure ) BK (Principal Diagnosis ) BR BQ Decimals are not required. BK - Principal Diagnosis Decimals are not required. If decimals present, following format must be used: Principal and Other Procedure The code must have two significant digits in front of the decimal There MUST be one digit following the decimal There can be a second digit following the decimal. Space in the second digit following the decimal is valid. Empire requires a principal diagnosis code for all claims regardless of the type of bill. BR - International Classification of Diseases Clinical Modification (ICD-9-CM) Principal Procedure BQ - International Classification of Diseases Clinical Modification (ICD-9-CM) Procedure 'BQ' repeats 12 times within segment HI Other Procedure Information segment If decimals are present, the following format must be followed: F O R M A T Principal and Other Procedure Format: The code must have two significant digits in front of the decimal There MUST be one digit following the decimal There can be a second digit following the decimal. Space in the second digit following the decimal is valid. Principal Diagnosis (BK) Decimals are not required. Admitting Diagnosis (BJ) Patient Reason for Visit (ZZ) If decimals present, following formats must be used: E- (BN) Other Diagnosis (BF) Diagnosis, Patient Reason for Visit and Other Diagnosis The code must have three significant digits in front of the decimal There can be two digits following the decimal. For example: 872.0, , V02.5, and V02.51 are valid. E- Diagnosis codes which contain an 'E' in the first position: The code must have 4 digits prior to the decimal. Spaces after the decimal are considered valid. For example: E849 and E849.1 are valid. E84.91 is invalid. Page 15 of 16 Release 2 Version A1 - Oct 2002

16 Loop ID 2310A Attending Physician Name P.326 NM1 NM108 Attending Physician Name Loop ID 2310B Operating Physician Name P.333 NM1 NM108 Operating Physician Name Loop ID 2310C Other Provider Name P.340 NM1 NM108 Other Provider Name Loop ID 2320 Other Subscriber Information P.357 SBR SBR09 Other Subscriber Claim Filing Indicator Information Loop ID 2330B Other Payer Name P.408 NM1 Other Payer Name Loop ID 2400 Service Line P.439 SV2 SV202-1 Institutional Service Product/Service ID Line SV202-2 Product/Service ID P.448 DTP Service Line Date DTP02 Date Time Period Format Loop ID 2410 Drug Identification P.459 LIN LIN03 Drug Identification Product/Service ID Loop ID 2420A Drug Identification P.326 NM1 Attending Physician Name 837 Institutional Health Care Claim Detail Patient Hierarchical Level NM XX (Attending Physician Primary ID) XX (Operating Physician Primary ID) XX (Other Physician Primary ID) (See 837I IG p.357) (Other Payer Primary ID) 24 - Employer's Identification Number 34 - Social Security Number XX - HCFA National Provider Identifier Attending Physician ID number is not validated Employer's Identification Number 34 - Social Security Number XX - HCFA National Provider Identifier Operating Physician ID number is not validated Employer's Identification Number 34 - Social Security Number XX - HCFA National Provider Identifier Other Provider ID number is not validated. If value is 'MA' - Medicare Part A, then Loop 2330B must be '00308'. If value is '00308', then Loop 2320 SBR09 must be 'MA'. HC HC - HCPCS s (external code source 130) (Procedure ) Empire will support non-standard HCPCS codes for claim dates of service prior to 10/16/2003. For claim dates of service after 10/16/2003, standard HCPCS codes must be used. D8 RD8 (National Drug ) XX (Attending Physician Primary ID) For outpatient bills (as determined by type of bill), DTP02 must equal 'D8'. Empire recommends that the National Drug be sent without any hyphens Employer's Identification Number 34 - Social Security Number XX - HCFA National Provider Identifier Attending Physician ID number is not validated. Page 16 of 16 Release 2 Version A1 - Oct 2002