Objectives The purpose of these guidelines is to provide billing offices with information about several significant changes and features of the HIPAA-compliant professional claims transaction (837P). These include the following: Standard Code Sets Adjustments and Voids Number of Service Lines Coordination of Benefits Attachment Processing Ordering Physician Number Please note: further detailed information on exchanging HIPAAcompliant transactions with Anthem can be found in the 837P Companion Document located under Electronic Data Interchange (EDI) of the Provider section on the http:\\www.anthem.com website. Background Anthem Blue Cross and Blue Shield is a strong proponent of EDI transactions because they will significantly reduce administrative and operating costs, gain efficiency in processing time, and improve data quality. Under HIPAA, as EDI transactions gradually replace paper based transactions, the risk of losing documents, encountering delays and paper chasing is minimized. Where to Call If your practice is considering submitting electronically in the HIPAA-compliant format, please contact the EDI department for your area listed below. Connecticut: 1 (800) 922-1742 Professional Ext. 8293 New Hampshire: 1 (800) 807-2919 Maine: 1 (800) 334-8262 1
Standard Code Sets HIPAA Approved Code Sets HIPAA requires Anthem and all payers to use standard code sets. It is important to consult the current version of HIPAA approved code sets. The following is a list of the most commonly used HIPAA approved code sets for Professional billing: CPT 4 Codes (Current Procedural Terminology) for Professional services ICD 9 CM (Diagnostic) HCPCS (Health Care Financing Administration Common Procedure Coding System) used for all other medical services NDC (National Drug Codes) Used by retail pharmacies only CDT (Code on Dental Procedures and Nomenclatures) Claim Status Codes and Claim Adjustment Reason Codes Provider Taxonomy Codes (Indicates provider specialty) Elimination of Local Codes Keeping Current with HIPAA Standard Code Sets Sources for Code Sets If you have been instructed to use an administrative code/local code by Anthem in the past, please consult one of the above current publications for a code that best describes the particular billing service/procedure. Use of non-hipaa compliant codes will result in a claim failure. The latest editions of coding manuals are often available from your state professional associations/organizations. Anthem does not distribute coding manuals. If you are unable to obtain this information from your professional society, association/organization, the following list is a sampling of vendors to assist you in purchasing the most current publication of standard code sets. American Medical Association (Non members 1 (800) 621-8335 or visit the Internet at www.amapress.com). Members: 1 (800) 262-3211 American Hospital Association: 1 (800) 242-2626 National Uniform Billing Committee 1 (312) 422-3390 Contact your local Medical Bookstore or call: 1 (800) MED- SHOP. For Internet orders visit http://medicalbookstore.com 2
The 837 Professional Claims Transaction Compliance Deadline for HIPAA Compliant Transactions If your institution is conducting electronic transactions with Anthem, either through a vendor or directly, the HIPAA law requires that all transactions must be submitted in a HIPAAcompliant format by October 16, 2003. In July 2003, the Centers for Medicare and Medicaid Service issued its Guidance on Compliance with HIPAA transactions and Code Sets. This guidance did not extend or delay the deadline. It instead outlined the approach that the government plans to take regarding enforcement of the HIPAA transaction and code set provisions. Anthems Approach to Compliance HIPAA Compliant Format Anthem is prepared to accept and transmit HIPAA compliant transactions. Anthem also is prepared to continue accepting our current transactions during a brief transition period beginning October 16, 2003. Under the HIPAA Compliant format, there are changes that may impact some of the billing procedures within your office. It is important to first consult with your billing system vendor or the person in your organization responsible for your billing system to confirm if any of these changes may apply to your practice. An EDI User s Guide has been provided to them previously which provides further detail of the 837P transaction Adjustments/Voids on the 837 P Claims Transaction Effective with HIPAA, Anthem Blue Cross and Blue Shield has the capability to accept adjustments and voids electronically. Frequency codes The provider may submit an adjustment/void to an original 837P claim indicating the appropriate frequency code. If the claim is an adjustment, use frequency code 7 If the claim is a void, use frequency code 8 Processing Indicating the original claim number for the adjustment or void is helpful in the processing of the claim is preferred, but not required. The adjustment or voided claim will appear on a future remittance advice. Number of Line Items for the 835 P Claims Transaction 3
Anthem Accepts up to 49 lines Under HIPAA, the 837 P Claims transaction may have as many as 50 line items. Claims over 50 line items will fail. Splitting Claims In the case of certain Anthem products, claims in excess of 10 (or in the case of Blue Shield 65, 12 lines) will be split during processing. Identifying Split Claims on a Remittance Advice Examples of how claim number schemes will appear in split claim situations are shown in the following examples of claims billed with 30 line items. Please note that in each of these examples, the B indicates it is an electronic split claim, with the last digit indicating the sequencing: Example 1 Blue Shield 65 Split Claim Example 2 Connecticut Carve-Out AS/AT Split Claim Example 3 Maine Split Claims Claim Number 1234567 First Claim Splits (12 lines) Second Claim Split (12 lines) Third Claim Split (6 lines) Claim Number AS123456 First Claim Splits (10 lines) Second Claim Split (10 lines) Third Claim Split (10 lines) Claim Number AC123456 First Claim Splits (10 lines) Second Claim Split (10 lines) Third Claim Split (10 lines) Split Claim Number B1234560 B1234561 B1234562 Split Claim Number BS123450 BS123451 BS123452 Split Claim Number BC123450 BC123451 BC123452 4
Coordination of Benefits (COB) on the 837 P Claims Transaction COB Models HIPAA supports two COB models. Provider-to-Payer. Anthem Blue Cross and Blue Shield will use this model when conducting COB with other carriers (excluding Medicare Carriers). Provider to Payer to Payer. COB with Medicare follows the Provider-to-Payer-to-Payer model. Provided that you have the specific 837P data elements populated, the elements will work together to coordinate benefits between Anthem Blue Cross and Blue Shield and Medicare or other carriers. The 837 I Companion Document contains a table that identifies the data elements pertinent to each of the above models. This document is located under Electronic Data Interchange (EDI) of the Provider section of the http\\www.anthem.com website. Reminders when submitting a COB claim in an 837 format The proper payer sequencing is important when there is more than one payer involved on a claim. If Anthem Blue Cross and Blue Shield is the secondary payer, you must submit all the data elements from the primary payer. If Anthem Blue Cross and Blue Shield is the tertiary payer, you must submit all the data elements from both the primary and secondary payer. Attachments The attachment Indicator HIPAA requires all payers to accept an attachment indicator (documents to support a claim) electronically. Anthem has implemented the following process to all providers to submit their claims electronically when they require attachments. 5
Process for Sending Attachments with Electronic Claims This process should only be used for those procedures/services that require additional documentation for adjudication. If you are sending additional information to support an electronic claim submission, 837 P, you must do the following On your 837 P, populate Loop 2300, PWK02 with a value of BM (By Mail) Access the Anthem Attachment Face Sheet posted under the EDI section on the http:\\www.anthem.com website Send the completed Attachment Face Sheet to the appropriate address on the same day (or next business day) when you submitted your claim. All attachments must be received within 7 days of the electronic submission or your claim will be denied. Ordering Physicians on the 837 P Radiology Claims Effective with HIPAA compliant claims, Anthem requires claim submissions for all radiology services to include the Ordering Physician s name and identification number. 6