X A1 Addenda Companion Document - Professional (004010X098A1) - EFFECTIVE 05/23/07

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1 Companion Document 837I++ X A1 Addenda Companion Document - Professional (004010X098A1) - 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 (004010X098A1) implementation guide should be used for claim submission if you are currently submitting claims on the NSF electronic format. Based on the A1 (004010X098A1) 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 (004010X098A1) 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 Loops 2010AA Billing, 2310B and 20A Rendering sections 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 18 Release 3 ( ) 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. Item 1 Character Sets Supported by Empire 2 Multiple ISA through IEA s in a file with different Receiver ID s (ISA08). Empire BCBS Requirement 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. 3 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 . 4 Combined Claim Submissions This document only addresses claims for processing by Empire Blue Cross Blue Shield. Refer to the Professional Quicklink Companion Document for details on submitting commercial claims. 5 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. 6 Subscriber and Patient Last Must be Alpha and may contain one embedded space/hyphen. and First Name Formats 7 Subscriber and patient Must equal A-Z or blank. name middle initial format 8 Field Size Limitations External Code 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 5 positions, the valid field size would be a maximum of five positions. Example: For HCPCS, the IG allows for 30 positions. Since the HCPCS/CPT are five positions, the field size is reduced to 5 positions. Data Element 782 Refer to Appendix A in the X098A1 implementation guide. Data element 782 is limited to a maximum length of 10 characters including reported or implied places for cents. 9 X Acknowledgment Transaction An X Acknowledgment Transaction will be created for every claim functional group, GS through GE (GS01 equal to HC) submitted to Empire. 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. Page 2 of 18 Release 3 ( ) Version A1 - Oct 2002

3 Item 10 TA1 Interchange Acknowledgement 11 Front End Validation 12 Negative s in R defined fields 13 Service Line Charge Amounts 14 Type of Service Code in the National Standard Format (NSF) 15 Service Line Units 16 Group Number Format 17 Subscriber and Patient Loops 18 Delimiters 19 Submission of Electronic Adjustments Empire BCBS Requirement As the 837 transaction is processed through our translator, a TA1 acknowledgment will be generated if there are any errors in the ISA and GS segments. These errors will be reported on the Empire Receipt Report under the Transmission Summary section. 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. The levels of editing performed in the front-end system will be documented separately. 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. Empire requires at least one service line with a dollar amount greater than zero. The Type of Service code is not supported in the X version 4010A1 transaction. Use service line modifiers when applicable to the service line. The modifiers are submitted in Loop 00 SV1 segment. 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. 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. 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. Empire recommends using the delimiters defined in section A Use of other characters can be discussed during the testing period with trading partners. Character Name Delimiter * Asterisk Data Element Separator : Colon Sub-Element Separator ~ Tilde Segment Terminator 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. 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 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. Page 3 of 18 Release 3 ( ) Version A1 - Oct 2002

4 Item 20 Number used for Blue Shield Claims Processing (Updated February 2006) Continue to submit the Empire assigned provider number (EPIN) Update May 2007 Prepare for submitting NPI only effective 5/23/07 during contingency period through 1/25/08 Empire BCBS Requirement The Rendering ID in Loop 2310B is only required if different than the Billing in Loop 2010AA or the Pay-To in Loop 2010AB. Empire will not use or validate the Pay to in Loop 2010AB for claims processing. Empire will process the claim as follows: If 2010AA is present with a valid BS Number and Loops 2310B or 20A are not present, the Billing ID in Loop 2010AA will be used for claims processing. If the Rendering ID is present in 2310B and differs from the Billing ID in Loop 2010AA, the Rendering ID in Loop 2310B will be used for claims processing. We strongly recommend not using the Rendering ID at the service level in Loop 20A. However, If 20A is present on each service line, the following will occur: If the Rendering ID s are the same on each service line, the Rendering ID in Loop 20A will be used for claims processing. The ID s in Loop 2010AA and 2310B will not be used for claims processing. If the Rendering ID s are different on the service lines, the Rendering ID in Loop 2310B will be used if different from what is in Loop 2010AA. If the Rendering ID in Loop 2310B is not present or is equal to the Billing ID in Loop 2010AA, then the Billing ID in Loop 2010AA will be used for claims processing. If the NPI is submitted in the NM109 with '' in Loops 2010AA, 2310B or 20A, then the provider's Federal Tax ID Number or Social Security Number must be present in the REF segment of the same loop with REF01 equal to either EI or SY. The EI qualifier is required unless the provider does not have a Federal Tax ID number. If the provider does not have a Federal Tax ID Number, then the SY qualifier is required. The Federal Tax ID Number or Social Security Number will be edited against internal files for validity. If both the Federal Tax ID Number and Social Security Number are present, the Federal Tax ID number will be edited for validity. Adjudication for professional claims uses provider loops 2010AA Billing, 2310B Rendering (claim level), and 20A Rendering (line level). 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 NM109 and Federal Tax ID in Loop 2010AA REF02. 2) accepting claims submitted with EPIN in Loop 2010AA REF02 and Federal Tax ID in Loop 2010AA NM109. 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 the detail section of this document Loops 2010AA, 2310B, and 20A for reference to the new contingency period extension implemented through January 25, Page 4 of 18 Release 3 ( ) Version A1 - Oct 2002

5 Item 21 Empire Number Format (Updated February 2006) 22 Empire Payer ID Format 23 Hierarchical Level Data Structure Empire BCBS Requirement Positions 1-2 Individual Only: Enter two alpha characters identifying the initials of the s first and last name. For ex., JS John Smith. Group Only: Enter the first two characters of the Group or Corporate Name (first letter of the Group or Corporate Name may be followed by a blank). For ex., WE for West Medical Group. If the has a long last name, for ex., a hyphenated last name, the first 2 alpha characters of the provider's last name are used Position 3 Must contain a zero Position 4-8 Must contain the provider code Position 9 Must equal the provider s office where services were rendered (Address code 1, 2, 3) Position 10 Must contain a zero If more than one provider treats the same patient, a separate claim must be submitted for each provider. When Empire is identified as the payer, the first two positions of the Payer ID must equal '00' followed by the plan code, 803. Example, For non-empire subscribers, the first two positions of the Payer ID must equal 00 followed by the Plan Code on the subscriber s ID card. Please refer to section(s) , 2.3.2, and of the 837 Professional 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 (004010X098A1) defines the hierarchical structure as Information Source, Subscriber, Dependent. The information source in this implementation guide is the Billing. 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 18 Release 3 ( ) Version A1 - Oct 2002

6 Item 23 Hierarchical Level Data Structure (cont'd) 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. Federal Tax ID Number Requirement (Updated April 2005) (Updated February 2006) (Update November 30, 2006) Validation to Match NPI effective 5/23/07 Effective for 837 claim submissions submitted on or after April 22, 2005, the Federal Tax number that corresponds to the Empire Blue Shield billing provider and rendering provider numbers must be present and match to the Federal Tax identification number on the internal Empire provider file. See detail section for complete instructions. If the NPI is submitted in the NM109 with '' in Loops 2010AA, 2310B or 20A, then the provider's Federal Tax ID Number 'EI' or Social Security Number 'SY' must be present in the REF segment of the same loop. The EI qualifier is required, however, if the provider does not have a Federal Tax ID number, the 'SY' qualifier must be used. The Federal Tax ID Number or Social Security Number will be edited against internal files for validity. If they are both present, only the Federal Tax ID Number will be edited for validity. Beginning May 23, 2007, validation of either the Federal Tax ID number or Social Security Number will be done against internal files to ensure matching with the submitted NPI. Page 6 of 18 Release 3 ( ) Version A1 - Oct 2002

7 Item 25 R 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. Empire BCBS Requirement Please refer to section A in the 837 Implementation Guide for instructions on how to submit decimal data elements (Monetary Amounts). The implementation guide states: The decimal point always appears in the character stream if the decimal point is at any place other than the right end. If the value is an integer (decimal point at the right end) the decimal point should be omitted An example of an R data element is CLM02. There are many R data elements within the 837. 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* 26 Transmission File Size 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 7 of 18 Release 3 ( ) Version A1 - Oct 2002

8 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 837 Professional Health Care Claim Interchange Control Header (ISA) ISA Interchange Control Header ISA05 Interchange ID ISA06 Interchange Sender ID ISA07 Interchange ID ISA08 Interchange Receiver ID ISA09 Interchange Date ISA12 Interchange Control Version Number ISA14 Acknowledgment Requested ISA15 Usage Indicator ZZ (Submitter ID) ZZ BS803 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. 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 8 of 18 Release 3 ( ) Version A1 - Oct 2002

9 Segment 837 Professional Health Care Claim Functional Group Header (GS) GS Functional Group Header GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number (Submitter ID) BS803 (CCYYMMDD) (HHMM) (Assigned by Sender) Empire does not edit this element. The value submitted must meet the implementation guide attributes. BS803 - Empire Blue Shield claims 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. Empire requires the GS and GE control number to be unique within the ISA through IEA. The GS06 and GE02 control numbers must equal. GS08 Version / Release / Industry Identifier Code X098A1 Operationally used to identify the 837 Professional Health Care Claim transaction IG Segment Beginning of Hierarchical Transaction P.62 BHT BHT02 Beginning of Transaction Set Hierarchical Purpose Code Transaction BHT06 Transaction Type Code P.65 REF Transmission Type 837 Professional Health Care Claim Header REF02 Loop ID 1000B Receiver Name P.72 NM1 Receiver Name NM CH (Transmission Type Code) (Receiver Primary Identifier) Must equal 00 or 18. Empire will accept both values. Empire BCBS recognizes all submissions as chargeable. Must equal X098A1. 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 was submitted in GS03. Page 9 of 18 Release 3 ( ) Version A1 - Oct 2002

10 IG Segment Loop ID 2010AA Billing Name P.81 NM1 Billing Code P Professional Health Care Claim Detail Billing/Pay-to Hierarchical Level NM109 Code REF01 (Billing Primary ID) 1B EI SY 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. REF Billing Secondary REF02 (Billing Additional Identifier) - Employer's Number - HCFA National Identifier If NPI present in and NM109, then the Federal Tax ID or SSN must be present in the REF segment of this loop. If NPI not present, must equal the Federal Tax ID No. or SSN corresponding to BS provider no. submitted in REF segment (REF01 '1B'). REF02. This number will be validated against an internal file at Empire. An REF segment must be present with REF01 '1B' qualifying the REF02 Empire assigned BS provider number when does not equal ''. 1B - BS Number Empire recommends at least one REF segment with a 1B qualifier identifying the Empire BS provider no. reported in REF02 when billing NPI during this contingency period. EI - Employer's Number SY - Social Security Number If NPI present in 2010AA '' & NM109, then second REF segment required for REF01 EI & REF02 Federal Tax ID No. or REF01 'SY' & NM109 SSN. If the provider has a Federal Tax ID No., it must be submitted. If NPI not present and REF01 '1B, then 2010AA NM1 segment must be present for '' & NM109 Federal Tax ID No. or '' & NM109 SSN. If REF01 1B, REF02 must equal the 10 position Empire assigned BS provider no. This number is used for editing. The front-end edit documentation will contain complete requirements. If REF01 EI, REF02 must equal the provider's Federal Tax ID No. (if applicable) If REF01 SY', REF02 must equal the provider's SSN. If NPI present in & NM109, then a REF segment with either the Federal Tax ID No. or SSN is required. If the provider has a Federal Tax ID No., it must be submitted. If multiple REF segments present with Federal Tax ID No. and SSN, the Federal Tax ID No. will be validated. Page 10 of 18 Release 3 ( ) Version A1 - Oct 2002

11 IG Segment Loop ID 2000B Subscriber Hierarchical Level P.105 SBR Subscriber Information 837 Professional Health Care Claim Detail Subscriber Hierarchical Level SBR01 Payer Responsibility Sequence Number Code SBR03 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 Code BL - Blue Cross/Blue Shield Page 11 of 18 Release 3 ( ) Version A1 - Oct 2002

12 IG Segment 837 Professional Health Care Claim Detail Subscriber Hierarchical Level Loop ID 2010BA Subscriber Name P.112 NM1 NM102 1 Subscriber Entity Type Name MI NM109 (Subscriber Primary Identifier) 1 - Person MI - Member Number Submit the subscriber identification number as shown on Blue Shield 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 2010BB Payer Name P.1 NM1 Subscriber Information NM109 PI (Primary Payor ID) PI - Payor For Empire subscribers: The payer ID must equal For all non-empire subscribers: The first two positions must equal 00 followed by the plan code on the subscriber s ID card. Page 12 of 18 Release 3 ( ) Version A1 - Oct 2002

13 IG Segment Loop ID 2010CA Patient Name P.148 NM1 Patient Name 837 Professional Health Care Claim Detail Patient Hierarchical Level NM109 Identifcation Code Loop ID 2300 Claim Information MI (Patient Primary Identifier) Empire recommends sending no more than 5,000 claims per transmission. P.157 CLM Claim Information CLM01 Claim Submitter's Identifier CLM02 Monetary Amount CLM05-3 Claim Frequency Type Code (Patient Account Number) (Total Claim Charge (Claim Frequency Code) CHG DOS CHG Charges (Total or Line); DOS Date of Service; PVN DIA PVN Number; DIA Diagnosis; PRC Procedure Code; POS PRC OCA Place of Service; UNT Units of Service; MDF Modifier; OCA IDC TFD Other Carrier Allowance; IDC ID Number Change; DEP POS UNT MDF DEP Dependent Number Change; SOA Questioning Schedule of Allowance; MED Medical Necessity Appeal; AUT Authorization SOA MED on File Appeal Denial; TFD Timely Filing Denial Appeals; CDR AUT CDR Contractual Denial Review; OTH Other OTH (Related Causes Code) Empire will only store up to 20 positions for a patient account number as noted in the implementation guide. Total claim charge amount must equal the sum of the service line total charges (Loop 00, SV102). Must be equal to '1', '7' replacement (replacement of prior claim), or '8' void (void/cancel of prior claim) When CLM05-3 is '7' (adjustment) or '8' (void), value (listed) in the first three positions of NTE segment (NTE02) P.233 Loop 2300 Claim Note P.467 Loop 00 Line Note NTE02 CLM Related-Causes Code MI - Member Number Same requirements apply to the Subscriber and Patient Primary Identifiers. Must equal the Empire assigned subscriber identification number as shown on Blue Shield 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, 5) not contain low values 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. If 'AA' Auto Accident, location of where accident occurred must be populated in CLM11-4 (State or Province Code) and CLM11-5 (Country Code). Page 13 of 18 Release 3 ( ) Version A1 - Oct 2002

14 IG Segment Loop ID 2300 Claim Information (cont'd) P.199 PWK Claim PWK01 Report Type Code Supplemental Information Updated February 2006 P.216 REF Original Number (ICN/DCN) PWK02 AA Report BM Transmission Code EM FX PWK05 ID Code PWK06 REF02 IG edits IG0107, 114, and 066 P.195 CR1 Ambulance Transport Information P.1 CRC Ambulance Certification P.6 CRC Patient Condition Information: Vision P.254 HI Health Care Diagnosis Code Code 837 Professional Health Care Claim Detail Patient Hierarchical Level CR109, 110 Description CRC03-07 Condition Indicator CRC03-07 Condition Indicator HI01-1 Code List HI01-2 Industry Code (Attachment Report Type Code) AC (Attachment Control Number) (Claim Original Number) (Round Trip, Stretcher Purpose Description) (Condition Code) (Condition Code) BK (Diagnosis Code) CT Certification* Use when submitting the American Express Authorization Number *AA - Available on Request at Site BM - By Mail EM - FX - By Fax *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 Empire. 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. For CR1 and CRC segments, refer to the X A1 Professional Front-End Validation Manual for details on Please refer to IG edit IG0107 for a list of the procedure codes that Empire considers as ambulance services. Please refer to IG edit IG0114 for a list of the procedure codes that Empire considers as ambulance services. Please refer to IG edit IG0066 for a list of the procedure codes that Empire considers as vision services. BK - Principal Diagnosis ICD-9 Codes Empire does not process claims without a principal diagnosis code. Other diagnosis codes can be supplied in this data element. Page 14 of 18 Release 3 ( ) Version A1 - Oct 2002

15 IG Segment Loop ID 2310A Referring Name P.271 NM1 Referring Name NM109 Loop ID 2310B Rendering Name P.278 NM1 Rendering Name NM109 P.283 REF Rendering Secondary 837 Professional Health Care Claim Detail Patient Hierarchical Level REF01 REF02 (Referring Primary ID) (Rendering ID) 1B EI SY - Employer's Number - HCFA National Identifier Referring number is not validated. 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. (Rendering Secondary Identifier) - Employer's Number - HCFA National Identifier If REF01 '1B and NPI present in NM109, Empire requires a second REF segment populated with Federal Tax ID No. (REF01 'EI' & NM109) or SSN (REF01 'SY' & REF02). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. If REF01 '1B and NPI not present, Empire requires NM1 segment populated with Federal Tax ID No. ( '' & NM109) or SSN ( '' & NM109). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. The Federal Tax ID No. or the SSN must match to the provider number submitted with the 1B qualifier and must match the number on an Empire internal file. If the provider has a Federal Tax ID No., it must be submitted. 1B - Blue Shield Number EI - Employer's Number SY - Social Security Number If REF01 1B, REF02 must contain the 10 position Empire assigned BS provider number. If REF01 1B and NPI not present, then NM1 segment must be populated with Federal Tax ID No. ( '' & NM109) or SSN ( '' & NM109). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. If NPI present in and NM109, then a second REF segment must be populated with Federal Tax ID No. (REF01 'EI' & NM109) or SSN (REF01 'SY' & REF02). If the provider has a Federal Tax ID No., it must be submitted. Page 15 of 18 Release 3 ( ) Version A1 - Oct 2002

16 IG Segment Loop ID 2310C Purchased Service Name P.285 NM1 Purchased Service NM109 (Purchase Name Service Loop ID 2310D Service Facility Location P.290 NM1 Service Facility Location NM109 (Laboratory/F acility Loop ID 2310E Supervising Name P.298 NM1 Supervising Name NM109 (Supervising Loop ID 2320 Other Subscriber Information P.303 SBR Other Subscriber Information SBR09 Claim Filing Indicator Code (See 837P IG P.303) Loop ID 2330B Other Payer Name P.3 NM1 NM109 Other Payer Name Loop ID 00 Service Line P.383 SV1 SV101-1 Professional Product/Service ID Service SV101-2 Product/Service ID P.488 NTE Line Note 837 Professional Health Care Claim Detail Patient Hierarchical Level SV104 Quantity NTE02 Description (Other Payer Primary ID) - Employer's Number - HCFA National Identifier Purchase Service number is not validated. - Employer's Number - HCFA National Identifier Laboratory/Facility number is not validated. - Employer's Number - HCFA National Identifier Supervising number is not validated. If value is 'BL', then 2330B NM109 is: '00803' - Empire BS subscribers '00xxx' - non-empire subscribers where xxx is the plan code listed on subscriber's ID card coordinated with Loop 2320 SBR09 'BL': '00803' - Empire BS subscribers '00xxx' - non-empire subscribers where xxx is the plan code listed on subscriber's ID card HC HC - HCPCS Codes (external code source 130) (Procedure Code) (Service Unit Count) (Line Note Text) 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. must be greater than zero. When it is necessary to bill for unlisted HCPCS (NOC codes) in Loop 00 SV101-2 (Procedure Code), include the drug and dosage. Loop ID 10 Drug P.480 LIN LIN03 Drug Product/Service ID (National Drug Code) For Medicare Private Fee for Service claims, submit the dates when the provider assumed/relinquished patient to/from post-operative care Empire recommends that the National Drug Code be sent without any hyphens. Page 16 of 18 Release 3 ( ) Version A1 - Oct 2002

17 IG Segment Loop ID 20A Rendering Name P.488 NM1 Rendering Code Name P.493 REF Rendering Secondary NM109 Code REF01 REF Professional Health Care Claim Detail Patient Hierarchical Level (Rendering ID) 1B EI SY (Rendering Secondary Identifier) 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. - Employer's Number - HCFA National Identifier If REF01 '1B and NPI present in NM109, Empire requires a second REF segment populated with Federal Tax ID No. (REF01 'EI' & NM109) or SSN (REF01 'SY' & REF02). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. If REF01 '1B and NPI not present, Empire requires NM1 segment populated with Federal Tax ID No. ( '' & NM109) or SSN ( '' & NM109). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. The Federal Tax ID No. or the SSN must match to the provider number submitted with the 1B qualifier and must match the number on an Empire internal file. If the provider has a Federal Tax ID No., it must be submitted. 1B - Blue Shield Number EI - Employer's Number SY - Social Security Number If REF01 1B, REF02 must contain the 10 position Empire assigned BS provider number. If REF01 1B and NPI not present, then NM1 segment must be populated with Federal Tax ID No. ( '' & NM109) or SSN ( '' & NM109). Validation of these numbers is done against internal files to ensure matching of the EPIN to Tax ID No./SSN. If NPI present in and NM109, then a second REF segment must be populated with Federal Tax ID No. (REF01 'EI' & NM109) or SSN (REF01 'SY' & REF02). If the provider has a Federal Tax ID No., it must be submitted. Page 17 of 18 Release 3 ( ) Version A1 - Oct 2002

18 IG Segment Loop ID 20B Purchased Service Name P.495 NM1 Purchased Service NM109 (Purchased Name Service ID) Loop ID 20C Service Facility Location P.500 NM1 Service Facility Location NM109 (Laboratory/ Facility Primary Loop ID 20E Ordering Name P.513 NM1 Ordering Name NM109 (Order Primary ID) Loop ID 20F Referring Name P.5 NM1 Referrring Name NM Professional Health Care Claim Detail Patient Hierarchical Level (Referring Primary ID) - Employer's Number - HCFA National Identifier Purchased Service number is not validated. - Employer's Number - HCFA National Identifier Service Facility number is not validated. - Employer's Number - HCFA National Identifier Ordering number is not validated. - Employer's Number - HCFA National Identifier Referring number is not validated. Loop ID 20G Other Payer Prior Authorization or Referral Number P.531 NM1 Other Payer Prior - Employer's Number - HCFA National Identifier Authorization or Referral NM109 (Other Payer ID) Other Payer number is not validated. Number Page 18 of 18 Release 3 ( ) Version A1 - Oct 2002

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