ASC X Health Care Claim Specification

Transcription

1 AC X Health Care Claim pecification Interim Version 1.4 Healthix, Inc. 40 Worth t., 5 th Floor New York, NY Ext. 1 healthix.org About this Document April 28, 2015

2 ThisX Interim pecification document explains the functional specifications for a connection between Healthix and a participating organization for the purpose of receiving from claims (837) data. Important notes: This document maps to the HIPAA_5010:837apP standards The Healthix technical platform is being upgraded to Interystems Healthhare version Interim note: Healthix is currently building a new platform, whose development and testing may result in updates to this specification through mid Interim notes throughout this document highlight areas in which the specification is likely to change. Healthix X pecification Page 2 of 13

3 evision History Version Date Author Description 0.1 March 31, 2015 Nathan Hardesty-Dyck Draft for technical review ource documents: Interystems Preliminary X Member Enrollment Documentation (ev 2.0) Interystems Preliminary X Member Enrollment Documentation 0.2 April 3, 2015 Nathan Hardesty-Dyck Minor updates 0.3 April 10, 2015 Nathan Hardesty-Dyck Incorporate expert feedback 0.4 April 28, 2015 Nathan Hardesty-Dyck emove 834 into separate document. Now focus only on May 01, 2015 Naitik Patel Added Changes Business Process Updated hierarchical looping structure Created segment column in data mapping table. Added equired or ituational column in data mapping table Added more egments in data mapping table Added Examples of 837 file format 1.0 May 7, 2015 Naitik Patel Updated with outstanding comments from Mike and Nathan Published Interim version V May 12, 2015 Naitik Patel emoved all data elements pertaining to Monetary value 1.2 May 14, 2015 Naitik Patel Added changes 1.3 May 19, 2015 Naitik Patel Added Business scenarios for ubscriber s demographic information 1.4 ept. 22, 2016 Naitik Patel Added changes Healthix X pecification Page 3 of 13

4 Table of Contents 1 Introduction Transactions ending Data to Healthix: Process ummary Business process X12 Document tructure and Healthix Processing Health Care Claim (837) Example Healthix X pecification Page 4 of 13

5 1 Introduction X12 is a standard for electronic data interchange developed by the Accredited tandards Committee (AC) of the American National tandards Institute (ANI). The X12 standard contains hundreds of document types, a subset of which support the Health Insurance Portability and Accountability Act (HIPAA) requirement of widespread use of electronic data interchange in the United tates. HIPAA schemas (e.g. HIPAA_5010) further define the structure and characteristics of particular X12 document types. Healthix consolidates patient data in various formats and from many data sources. X12 documents provide important healthcare coverage and clinical data that Healthix adds to the unified patient record. This specification details the process of transmitting X12 documents to Healthix and the capability of Healthix to digest the documents data. The Healthix software platform is Interystems Healthhare Healthix supports the import of the following document types: Health Care Claim: HIPAA_5010:837apP Note that Healthix stores but does not display or use any financial information included in the adjudicated claims data it receives. Healthix X pecification Page 5 of 13

6 2 Transactions 2.1 ending Data to Healthix: Process ummary During implementation, Healthix provides credentials to the participant to enable the participant to access Healthix s ecure File Transfer Protocol (FTP) directory, used to submit X12 documents. Healthix processes new X12 documents on a constant basis. Healthix processes each incoming X12 document, extracting data according to the details provided later in this specification. After processing, the static X12 document itself may be archived or discarded. In either case, the Healthix system does not reference the static X12 document for the use or display of data. X12 document upload process: 1. Using an FTP client (e.g. WinCP), establish a connection to the Healthix FTP siteusing the FTP protocol (sftp:\\) a. The Healthix FTP host name is sftp.healthix.org(port 22) b. Healthix provides each participant with a FTP account and directory during project implementation 2. When prompted, authenticate using the credentials Healthix assigns during implementation 3. Transfer the X12 document(s) to the FTP site 4. Healthix processes the X12 documents as they arrive at the FTP site 2.2Business process Healthix will work with existing and prospective participants by taking their existing 837 and designing a new interface if necessary for each distinct formats. This is with the assumption that all participants have established claims business process on their end and are actively working with payers for the claims processes with their existing 837 format. Healthix will accommodate changes and mapping on its side to make sure that all the data segments that are coming across in 837 from different participant are sourced correctly into its database. Although Healthix s system Healthhare can store monetary segments that come across 837, due to data sensitivity, these segments has been removed from this specification document. ome Participants will not send subscriber s demographic information in 837 file. For these participants, Healthix will use MN to match the subscriber data and add claim record. If the MN doesn t exist in Healthix database for particular subscriber, the subscriber claim record will be rejected and will be sent back to participant on the error report. For Participants sending subscriber s demographic information on 837 file. If a subscriber comes across in 837 file without matching MN, Healthix will create a new record for such subscriber and record all the information provided in 837 file. Healthix X pecification Page 6 of 13

7 3 X12 Document tructure and Healthix Processing 3.1 Health Care Claim (837) Healthix supports the import of the Health Care Claims document HIPAA_5010:837apP (referred to as 837 in this specification). The 837 follows a hierarchical looping structure, with each loop indicated by an identifier (e.g. 2000A ): 1000A ubmitter 1000B eceiver 2000A Billing Provider 2010AA Billing Provider Name 2010AB Pay to the Address 2000B ubscriber 2010BA ubscriber econdary Identification 2010BB Payer Name 2300 Claim 2400 Claim Line 2100C- Provider 2100D-Patient 2200D-Claim The following table outlines the data that Healthix consumes from the 837. Any data elements not listed in this table are not currently stored within Healthix. equired ELEMENT ELEMENT DECIPTION Value DECIPTION Loop 1000A NM1 UBMITTE NAME-1000A 0 ENTITY IDENTIFIE CODE 41 ubmitter 0 ENTITY TYPE QUALIFIE 1, 2 1-Person, 2-Non-person entity 0 OGANIZATION NAME/LAT NAME ubmitter Name 0 FIT NAME ubscriber First Name 0 MIDDLE NAME ubscriber Middle Name NOT UED 0 NAME PEFIX NOT UED NOT UED 0 NAME UFFIX NOT UED 0 IDENTIFICATION CODE QUALIFIE 46 Electronic Transmitter ID number 0 IDENTIFICATION CODE ubmitter tax ID Loop 1000B NM1 ECEIVE NAME-1000B 0 ENTITY IDENTIFIE CODE 40 eceiver 0 ENTITY TYPE QUALIFIE 2 2-Non-person Entity 0 OGANIZATION NAME Payer Name eceiver name 0 NAME FIT 0 NAME MIDDLE 0 NAME PEFIX Healthix X pecification Page 7 of 13

8 NOT UED 0 NAME UFFIX NOT UED 0 IDENTIFICATION CODE QUALIFIE Electronic Transmitter ID number 0 IDENTIFICATION CODE eceiver Identifier Loop 2000B B UBCIBE INFOMATION 2000B 0 INDIVIDUAL PAYE EPONIBILITY ELATIONHIP EQUENCE CODE A - 18 H P,, T, U Primary Payer, econdary Payer If claim is for primary payer then P else if claim is for secondary pa 18-elf (required when subscriber is 0 EFEENCE IDENTIFICATION Group number 0 NAME Group name 0 INUANCE TYPE CODE Type of policy PAT PATIENT INFOMATION 2000B 0 DATE QUALIFIE D8 CCYYMMDD 0 DATE TIME PEIOD Date of death 0 UNIT CODE 01 Actual pounds 7 0 PATIENT WEIGHT Patient weight 0 YE/NO CONDITION O EPONE Y Pregnancy indicator Loop 2010BA NM1 UBCIBE ECONDAY 0 ENTITY IDENTIFIE CODE IL Insured or subscriber 0 ENTITY TYPE QUALIFIE 1 Person 0 NAME LAT ubscriber last name 0 NAME FIT ubscriber first name 0 NAME MIDDLE ubscriber middle name NOT UED 0 NAME PEFIX NOT UED N N NAME UFFIX ubscriber suffix IDENTIFICATION CODE QUALIFIE II, MI Member Identification number IDENTIFICATION CODE UBCIBE ADDE 2010BA ADDE INFOMATION MVP subscriber member number ubscriber address ADDE INFOMATION ubscriber address 2 UBCIBE ADDE 2010BA CITY NAME TATE POTAL CODE ubscriber City ubscriber tate ubscriber Zip code DMG UBCIBE DEMOGAPHIC 0 INFOMATION DATE 2010BA QUALIFIE D8 CCYYMMDD 10 DATE TIME PEIOD ubscriber date of birth 20 3 GENDE CODE F, M, U Female, male, unknown Loop 2010BB NM1 PAYE NAME 0 1 ENTITY IDENTIFIE CODE P Payer Healthix X pecification Page 8 of 13

9 0 ENTITY TYPE DECIPTION 2 Non-Person Entity 0 NAME LAT O OGANIZATION Payer Org. Name Payer Name 0 NAME FIT 0 NAME MIDDLE 0 NAME PEFIX 0 NAME UFFIX 0 IDENTIFICATION CODE QUALIFE XV, PI Payer Identification PI Prior to mandated 0 IDENTIFICATION CODE NUMBE MVP Health Care s Tax Identification N PAYE ADDE 2010BB 0 ADDE INFOMATION PAYE ADDE LINE 0 ADDE INFOMATION PAYE ADDE LINE N PAYE CITY, TATE, ZIP CODE 0 CITY NAME FEEFOM PAYE CITY NAME 0 TATE O POVINCE CODE PAYE TATE O POVINCE CODE 0 POTAL CODE PAYE POTAL ZONE O ZIP CODE 0 COUNTY CODE LOOP 2300 CLM CLAIM INFOMATION CLAIM UBMITTE' IDENTIFIE Patient account number 0 HEALTH CAE EVICE LOCATION Place of service 05-1 FACILITY CODE VALUE Facility code 05-2 FACILITY CODE QUALIFIE B Place of service Codes for Professional or 05-3 CLAIM FEQUENCY TYPE Original-claim frequency 0 EPONE CODE Y or N Provider signature on file 60 POVIDE ACCEPT AIGN A, B, C Provider accept Medicare assignment code ELATED CAUE CODE AA, EM, OA Auto Accident, Employment, Other 11-2 ELATED CAUE CODE AA, EM, OA Accident Used if more than 1 applies 11-4 TATE tate where accident occurred 11-5 COUNTY Country where accident occurred PECIAL POGAM CODE DELAY EAON CODE DTP DATE - LAT EEN DATE 2300 pecial circumstances Delay reason code 01 DATE/TIME QUALIFIE 304 Last Visit or Consultation 02 DATE TIME PEIOD FOMAT D8 Date format: CCYYMMCC 03 DATE QUALIFIE TIME PEIOD Last Visit or Consultation DTP DATE OF ADMIION DATE QUALIFIE 435 Admission date DATE FOMAT D8 Date format: CCYYMMDD DATE ADMIION DTP DATE OF DICHAGE 2300 Date of Admission Healthix X pecification Page 9 of 13

10 0 DATE QUALIFIE 096 Discharge date 0 DATE FOMAT D8 Date format: CCYYMMDD 0 DATE DICHAGE Date of Discharge 2300 H HEALTH CAE DIAGNOI CODE HI01 HEALTH CAE CODE INFOMATION HI01-1 CODE LIT QUALIFIE ABK, BK Principal diagnosis ICD-9 codes HI01-2 DIAGNOI CODE Diagnosis code HI01-3 DATE, TIME PEIOD FOMAT HI01-4 DATE TIME PEIOD HI01-6 QUANITY HI02-1 DIAGNOI TYPE CODE HI02-2 DIAGNOI CODE DIAGNOI CODE HI02-3 DATE, TIME PEIOD FOMAT HI02-4 DATE TIME PEIOD HI03 HEALTH CAE CODE INFOMATION DIAGNOI CODE HI03-1 DIAGNOI TYPE CODE ABF, BF HI03-2 DIAGNOI CODE HI03 HEALTH CAE CODE INFOMATION HI03-1 DIAGNOI TYPE CODE ABF, BF DIAGNOI CODE HI03-2 DIAGNOI CODE DIAGNOI CODE HI03-3 DATE TIME PEIOD FOMAT HI04 HEALTH CAE CODE INFOMATION DIAGNOI ICD-9 CODE HI04-1 DIAGNOI TYPE CODE ABF, BF DIAGNOI CODE HI04-2 DIAGNOI CODE HI05 HEALTH CAE CODE INFOMATION HI05-1 DIAGNOI TYPE CODE ABF, BF HI05-2 DIAGNOI CODE HI06 HEALTH CAE CODE INFOMATION HI06-1 DIAGNOI TYPE CODE HI06-2 DIAGNOI CODE HI07 HEALTH CAE CODE INFOMATION HI07-1 DIAGNOI TYPE CODE HI07-2 DIAGNOI CODE HI08 HEALTH CAE CODE INFOMATION HI08-1 DIAGNOI TYPE CODE HI08-2 DIAGNOI CODE Loop 2310A NM1 EFEING POVIDE NAME 2310A ABF, BF ABF, BF ABF, BF DIAGNOI CODE DIAGNOI CODE DIAGNOI CODE ENTITY IDENTIFIE CODE DN eferring provider ENTITY TYPE 1 MUT BE A PEON LAT NAME eferring physician last name Healthix X pecification Page 10 of 13

11 0 FIT NAME eferring physician first name 0 NAME MIDDLE eferring physician middle initial 0 NAME UFFIX eferring physician suffix 0 IDENTIFICATION CODE QUALIFIE XX National Provider ID 0 IDENTIFICATION CODE NPI Number Loop 2310B NM1 ENDEING POVIDE NAME 0 ENTITY IDENTIFIE CODE 82 endering provider 0 ENTITY TYPE QUALIFIE 1 Person 0 NAME LAT O OGANIZATION endering provider last name 0 NAME FIT endering provider first name 0 NAME MIDDLE endering provider middle initial 0 NAME UFFIX endering provider suffix 0 IDENTIFICATION CODE QUALIFIE XX National Provider ID 0 IDENTIFICATION CODE NPI Number 2310C NM1 EVICE FACILITY LOCATION 2310C 0 ENTITY IDENTIFIE CODE ervice location 0 ENTITY TYPE QUALIFIE 2 Non-person entity 0 NAME LAT O OGANIZATION Laboratory/facility name 0 NAME FIT 0 NAME MIDDLE 0 NAME PEFIX 0 NAME UFFIX 0 IDENTIFICATION CODE QUALIFIE XX National Provider ID 0 IDENTIFICATION CODE NPI Number V 9 POFEIONAL EVICE COMPOITE MEDICAL POCEDUE E, HC, IV, WK HC-HCPC codes, 01-2 PODUCT/EVICE IDENTIFIE ID Procedure Code 01-3 POCEDUE MODIFIE Procedure Modifier POCEDUE MODIFIE Procedure Modifier POCEDUE MODIFIE Procedure Modifier POCEDUE MODIFIE Procedure Modifier DECIPTION FEEFOM DEFINITIVE DECIPTION OF PODUCT/ EVICE ID POCEDUE Line item charge CODE amount V103 MINUTE (ANETHEIA) MJ MINUTE - Effective 7/1/2010 V104 QUANTITY MINUTE 0 FACILITY CODE VALUE Place of service 50 EVICE TYPE CODE 60 DIAGNOI CODE POINTE DIAGNOI CODE POINTE Diagnosis Code Pointer 07-2 DIAGNOI CODE POINTE Diagnosis Code Pointer 07-3 DIAGNOI CODE POINTE Diagnosis Code Pointer 07-4 DIAGNOI CODE POINTE Diagnosis Code Pointer 0 9 YE/NO INDICATO Y Emergency indicator Healthix X pecification Page 11 of 13

12 DTP DATE- EVICE DATE 0 DATE/TIME QUALIFIE 472 EVICE DATE QUALIFIE 0 DATE/TIME FOMAT D8, D8 Date Time Period Format Qualifier 0 DATE/TIME PEIOD CCYYMMDD- EVICE DATE 3.2 Example837 Description Data element separator ub-element separator epetition separator egment Terminator Default Delimiter * Asterisk : Colon ^ Carrot ~ Tilde IA*00* *00* *ZZ* *33* *110406*0857*^*00501* *1*P*:~ G*HC* * * *0857*312*X*005010X222A1~ T*837*0001*005010X222A1~ BHT*0019*00*1* *085755*CH~ NM1*41*2*LINE MEDICAL AOCIATE*****46* ~ PE*IC*KEVIN*TE* ~ NM1*40*2*UPMC*****46* ~ HL*1**20*1~ PV*BI*ZZ* X~ NM1*85*1*LINE*WILLIAM*J***XX* ~ N3*123 PEPPE T~ N4*PITTBUGH*PA*15123~ EF*EI* ~ PE*IC* KEVIN*TE* ~ HL*2*1*22*0~ B*P*18**BET UPMC FO YOU*****CI~ NM1*IL*1*KENT*CLAK****MI* ~ N3*123 FAKE TEET~ N4*PITTBUGH*PA*15123~ DMG*D8* *M~ NM1*P*2*UPMC HEALTH PLAN*****PI* ~ N3*1 CHATHAM CENTE 112 WAHINGTON*PO BOX 2995~ N4*PITTBUGH*PA*15230~ CLM* *47.28***11::1*Y*A*Y*Y*B~ DTP*304*D8* ~ DTP*431*D8* ~ EF*D9* ~ HI*BK:V053*BF:V068*BF:V0382~ NM1*77*2*DOCTO OFFICE*****XX* ~ N3*123 PEPPE T~ N4*PITTBUGH*PA*15123~ LX*1~ V1*HC:90744*15.76*UN*1*11**1~ DTP*472*D8* ~ LIN**N4* ~ LX*2~ V1*HC:90698*15.76*UN*1*11**2~ Healthix X pecification Page 12 of 13

13 DTP*472*D8* ~ LIN**N4* ~ LX*3~ V1*HC:90670*15.76*UN*1*11**3~ DTP*472*D8* ~ E*41*0001~ GE*1*312~ IEA*1* ~ Healthix X pecification Page 13 of 13