276 STATUS REQUEST - Inbound Translation

Transcription

1 INTECHANGE CONTOL HEADE 276 TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG IA01 Auth Infmation 00 No auth info present 03 Additional data infmation B3 2 2 The following group of segments is found in Appendix B3 of the Implementation Guide. IA02 Authization Infmation B IA03 ecurity Info 00 No info present 01 Pawd B4 2 2 IA04 ecurity Infmation B IA05 Interchange ID ZZ Mutually Defined B4 2 2 NHP uses ZZ Mutually Defined as the default. (Appendix B4 - IA05) IA06 Interchange ender ID B The Trading Partner agreement determines the Interchange ender ID number. ender number will be mutually defined as indicated in IA05 (IA06) IA07 Interchange ID ZZ Mutually Defined B4 2 2 NHP uses ZZ Mutually Defined as the default. (Appendix B4 - IA05) IA08 Interchange eceiver ID B This is the NHP number that the sender aigned (IA08) IA09 Interchange Date YYMMDD B5 6 6 IA10 Interchange Time HHMM B5 4 4 IA11 Interchange Control tds. U B5 1 1 Identifier IA12 Interchange Control Version No B5 5 5 IA13 Interchange Control No. B5 9 9 This numeric field must be the same as IEA02, Change Control Trailer, Interchange Control No. IA14 Acknowledgment equested 0 No acknowledgement requested 1 Acknowledgement requested B6 1 1 IA15 Usage Indicat P Production data T Test data IA16 Component Element eparat B6 1 1 B6 1 1 Our Trading Partner agreement specifies that NHP will determine when file is put in production. NHP will notify the sender via phone. (IA15) FUNCTIONAL GOUP HEADE G01 Functional ID Code H Health Care Claim tatus equest (276) B8 2 2 G02 Application ender's Code B Application enders Code and other Functional Group Header infmation is coded as agreed to in our Trading Partner Agreement with you. (G02) G03 Applicaton eceiver's Code B Code agreed to in Trading Partner Agreement (G03) G04 Date Fmat CCYYMMDD B8 8 8 G05 Time Fmat HHMM (recommended), HHMM, HHMMD, HHMMDD B Companion Guide el 1v0 - Appendix D.xls 1 of 6 Published October 2003

2 276 TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG G06 Group Control No. Numeric B9 1 9 G06 must match GE02 (Functional Group Trailer). ender aigns the number. eturned on the 997 (G06) G07 esponsible Agency Code X Accredited tandards B9 1 2 Committee X 12 G08 Version/elease/Industry ID Code X093A1 B TANACTION ET HEADE T01 Transaction et Identifier Code T02 Transaction et Control BEGINNING OF HIEACHICAL TANACTION The value int02 must be identical to E02. BHT01 Hierarchical tructure Code 0010 Infmation ource, Infmation eceiver, Provider of ervice, ubscriber, Dependent BHT02 Transaction et Purpose Code 13 equest BHT04 Transaction et Creation Date Fmat CCYYMMDD A INFOMATION OUCE LEVEL HL01 Hierarchical ID HL03 Hierarchical Level Code 20 Infmation ource HL04 Hierarchical Child Code 1 Additonal subdinate HL Data in this Hierarchical tructure A PAYE NAME NM101 Payer Entity ID Code P Payer NM102 Payer Entity Type 2 Non-Person Entity NM103 Payer Name NHP Payer name NM108 Payer Identification Code PI Payer Identification NM109 Payer Identification Code NHP requires the Provider as referenced in NHP's Trading Partner Agreement. PAYE CONTACT INFOMATION 2100A proce a request f status. 2000B INFOMATION ECEIVE LEVEL HL01 Hierarchical ID HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 21 Infmation eceiver Companion Guide el 1v0 - Appendix D.xls 2 of 6 Published October 2003

3 HL TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG Hierarchical Child Code 1 Additional ubdinate HL Data in this Hierarchical tructure B INFOMATION ECEIVE NAME NM101 ender Entity ID Code 41 UBMITTE NM102 ender Entity Type 1 Person 2 Non-Person Entity NM103 ender Name Last Organization Name NM104 ender First Name equired if Entity Type is a 1. NM105 ender Middle Name NM107 ender Name uffix NM108 ender Identification Code 46 Electronic Transmitter Identification (ETIN) NM109 ender Identification Code Code agreed to in Trading Partner Agreement. Must match code in G C EVICE POVIDE LEVEL HL01 Hierarchical ID HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 19 Provider of ervice HL04 Hierarchical Child Code 1 Additional ubdinate HL Data in this Hierarchical tructure C POVIDE NAME NM101 Provider Entity ID Code 1P Provider NM102 Provider Entity Type 1 Person 2 Non-Person Entity NM103 Provider Last Organization Name NM104 Provider First Name NM105 Provider Middle Name NM106 Provider Name Prefix NM107 Provider Name uffix NM108 Provider Identification Code V ervice Provider NM109 Provider Identification Code ubmitter Identifier value from the submitted claim ( AA, EF02 - NHP Vend ID ) 2000D UBCIBE LEVEL HL01 Hierarchical ID Companion Guide el 1v0 - Appendix D.xls 3 of 6 Published October 2003

4 2100D 276 TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG HL02 Hierarchical Parent ID HL03 Hierarchical Level Code 22 ubscriber HL04 Hierarchical Child Code 0 No ubdinate HL in this Hierarchical tructure UBCIBE DEMOGAPHIC INFOMATION 2000D DMG01 Date Time Period Fmat DMG02 Date Time Period / ubscriber birth date DMG03 ubscriber Gender Code UBCIBE NAME D8 Date expreed in fmat CCYYMMDD F Female M Male U Unknown NM101 ubscriber Entity ID Code IL ubscriber/insured NM102 ubscriber Entity Type 1 Person NM103 ubscriber Last Name NM104 ubscriber First Name NM105 ubscriber Middle Name NM106 ubscriber Name Prefix NM107 ubscriber Name uffix NM108 ubscriber Identification Code MI Member ID NM109 ubscriber Identification Code NHP Member ID 2200D CLAIM UBMITTE TACE NUMBE TN01 Trace Type Code 1 Current Trans. Trace s TN02 eference Identification/Trace Patient Account used in 837 CLM01 PAYE CLAIM IDENTIFICATION NUMBE 2200D EF01 Payer Claim eference Identification 1K Payer's Claim EF02 Payer Claim Control NHP Claim INTITUTIONAL BILL TYPE IDENTIFICATION 2200D MEDICAL ECOD IDENTIFICATION 2200D GOUP NUMBE 2200D proce a request f status. proce a request f status. proce a request f status. 276 Companion Guide el 1v0 - Appendix D.xls 4 of 6 Published October 2003

5 276 TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG CLAIM UBMITTED CHAGE 2200D AMT01 Claim Amount Code T3 Total ubmitted Charges epeat: 1 This loop is required because NHP recognizes the patient as the subscriber. AMT02 Claim Monetary Amount Total claim charge N AMT03 Credit/Debit Flag Code Not Used CLAIM EVICE DATE 2200D 2210D 2000E 2100E 2200E 2210E DTP01 Claim Date/Time 232 Claim tatement Period tart DTP02 Claim Date Time Period Fmat D DTP03 Claim Date Time Period ervice period date expreed as CCYYMMDD-CCYYMMDD EVICE LINE INFOMATION EVICE LINE ITEM IDENTIFICATION 2210D EVICE LINE DATE 2210D DEPENDENT LEVEL DEPENDENT DEMOGAPHIC INFOMATION 2000E DEPENDENT NAME CLAIM UBMITTE TACE NUMBE PAYE CLAIM IDENTIFICATION NUMBE 2200E INTITUTIONAL BILL TYPE IDENTIFICATION 2200E MEDICAL ECOD IDENTIFICATION 2200E CLAIM UBMITTED CHAGE 2200E CLAIM EVICE DATE 2200E EVICE LINE INFOMATION EVICE LINE ITEM IDENTIFICATION 2210E EVICE LINE DATE 2210E NHP will only allow request at the claim level. proce a request f status. proce a request. proce a request. proce a request. proce a request. TANACTION ET TAILE E01 Transaction Count E02 Transaction et Control Must match Transaction et Header T Companion Guide el 1v0 - Appendix D.xls 5 of 6 Published October 2003

6 FUNCTIONAL GOUP TAILE 276 TATU EQUET - Inbound Translation ANI 276 Name Allowable Data Values IG GE01 of Transactions ent B Numeric GE02 Group Control No. B Must match Functional Group Header G06. INTECHANGE CONTOL TAILE IEA01 of Functional Groups B7 1 5 Numeric IEA02 Interchange Control No. B7 9 9 This segment match IA13 in Interchange Control Header at the front of this document. -- ender provides. 276 Companion Guide el 1v0 - Appendix D.xls 6 of 6 Published October 2003