I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R M A N U A L Chapter 3: Electronic Solutions Library Reference Number: PRPR10004 3-1
Chapter 3: Revision History Version Date Reason for Revisions Completed By 1.0 September, 1999 Policies and procedures are current as of March 1, 1999 2.0 June 2001 Policies and procedures are current as of June 1, 2000 3.0 April 2002 Policies and procedures are current as of August 1, 2001 4.0 April 2003 Policies and procedures are current as of April 1, 2002 5.0 July 2004 Policies and procedures current as of January 1, 2004 5.1 March 2005 Policies and procedures current as of January 1, 2005 6.0 December 2006 Policies and procedures current as of April 1, 2006 7.1 February 2008 Policies and procedures as of October 1, 2007 8.0 August 2008 Policies and procedures as of February 1, 2008 8.1 October 2008 Policies and procedures as of August 1, 2008 9.0 March 2009 Policies and procedures as of February 1, 2009 New Manual Chapters 1, 2, 3, 6, 7, 8, 9, 10, 13, 14, and Appendix A All Chapters All Chapters All Chapters Quarterly Update Quarterly Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update EDS Document Management Unit EDS Document Management Unit EDS Client Services and EDS Publications Unit EDS Client Services and EDS Publications Unit EDS Client Services Department EDS Publications Unit EDS Publications Unit EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units EDS Provider Relations and Publications Units Library Reference Number: PRPR10004 1-2
Chapter 3 Revision History Indiana Health Coverage Programs Provider Manual Version Date Reason for Revisions Completed By 9.1 February 16, 2010 Policies and procedures as of August 1, 2009 10.0 March 4, 2010 Policies and procedures as of February 1, 2010 10.1 December 7, 2010 Policies and procedures as of August 1, 2010 11.0 March 22, 2011 Policies and procedures as of February 1, 2011 11.1 Policies and procedures as of August 1, 2011 Published October 11, 2011 12.0 Policies and procedures as of March 1, 2012 Published: June 5, 2012 12.1 Policies and procedures as of September 1, 2012 Published: November 8, 2012 13.0 Policies and procedures as of March 1, 2013 Published: April 30, 2013 13.1 Policies and procedures as of October 1, 2013 Published: October 31, 2013 14.0 Policies and procedures as of April 1, 2014 Published: May 13, 2014 14.1 Policies and procedures as of September 1, 2014 Published: October 28, 2014 15.0 Policies and procedures as of January 1, 2015 Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Semiannual Update Updated Claim Submission on Web interchange section Updated Voids and Replacements on Web interchange section Updated Check/RA Inquiry on Web interchange section Updated Automated Voice Response System section HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units HP Provider Relations and Publications Units Library Reference Number: PRPR10004 1-3
Chapter 3 Revision History Indiana Health Coverage Programs Provider Manual 1-4 Library Reference Number: PRPR10004
Chapter 3: Table of Contents Section 1: Introduction to Electronic Solutions... 3-7 General Information... 3-7 Section 2: Electronic Transactions... 3-8 HIPAA Compliance... 3-8 Electronic Transaction Types... 3-8 Electronic Standards... 3-9 Companion Guides... 3-9 Connectivity Options... 3-9 CORE Web Services... 3-10 File Exchange... 3-10 270/271 Eligibility Benefit Inquiry and Response... 3-10 837 Health Care Claim... 3-11 276/277 Health Care Claim Status Request and Response... 3-11 835 Health Care Claim Payment/Advice... 3-11 278 Health Care Services Review Request and Response (Prior Authorization)... 3-11 999 Acknowledgement... 3-12 Submission Summary Report... 3-12 Section 3: Web interchange... 3-13 Overview... 3-13 Web interchange Features... 3-13 System Requirements... 3-13 Web interchange Security... 3-14 Web interchange Password Regulations... 3-14 Web interchange Audit Reports... 3-14 Web interchange Administrator... 3-15 Eligibility Inquiry on Web interchange... 3-16 Claim Submission on Web interchange... 3-17 Voids and Replacements on Web interchange... 3-17 Coordination of Benefits Information in Web interchange... 3-18 User Lists on Web interchange... 3-18 Claim Inquiry on Web interchange... 3-18 Check/RA Inquiry on Web interchange... 3-19 NOP Inquiry on Web interchange... 3-19 Prior Authorization Submission on Web interchange... 3-19 Prior Authorization Inquiry on Web interchange... 3-20 Provider Profile on Web interchange... 3-20 User Profile on Web interchange... 3-21 Section 4: Electronic Data Interchange Trading Partner Process... 3-22 Overview... 3-22 Trading Partners... 3-22 Providers Not Required to Become an IHCP Trading Partner... 3-22 Trading Partner Procedures... 3-22 Trading Partner Profile... 3-23 SoftwareTesting Process... 3-23 Complete the Trading Partner Profile... 3-23 Conduct Application Development... 3-24 Library Reference Number: PRPR10004 3-5
Chapter 3 Table of Contents Indiana Health Coverage Programs Provider Manual Test... 3-24 Software Approval Process... 3-24 Software Vendor... 3-24 Clearinghouse, Value Added Network, Managed Care Entity... 3-25 Production Trading Partner Enrollment Process... 3-25 Complete a Trading Partner Profile... 3-25 Complete a Trading Partner Agreement... 3-25... 3-26 Introduction... 3-26 AVR System Telephone Number... 3-26 How to Use the AVR System... 3-26 AVR Call Limitations... 3-27 Quick-Entry Techniques... 3-27 Entering Alphabetic Data... 3-28 AVR System Walkthrough... 3-29 Global Messages... 3-29 Initial Options for AVR System... 3-31 NPI and LPI Validation... 3-33 Member Eligibility... 3-34 Service Restrictions... 3-37 Other Insurance Information... 3-41 Benefit Limits... 3-44 Check Write... 3-47 Prior Authorization... 3-48 Prior Authorization Inquiry Using Prior Authorization Number... 3-49 Prior Authorization Inquiry Using Member Identification Number... 3-52 Claim Status Inquiry... 3-57 Index... 3-62 3-6 Library Reference Number: PRPR10004
Section 1: Introduction to Electronic Solutions General Information Electronic Solutions refers to the means by which providers exchange data electronically with the Indiana Health Coverage Programs (IHCP). Various applications and transactions are available for providers that exchange data with the IHCP using electronic data interchange (EDI). This chapter covers the following items: Section 1: Introduction to Electronic Solutions Section 2: Electronic Transactions Section 3: Web interchange Section 4: Electronic Data Interchange Trading Partner Process Section 5: Automated Voice Response (AVR) System. Library Reference Number: PRPR10004 3-7
Section 2: Electronic Transactions HIPAA Compliance The Indiana Health Coverage Programs (IHCP) is compliant with the Administrative Simplification provision of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. This provision mandates standard electronic transactions and code sets across the healthcare industry, standardizing electronic data interchange (EDI) to provide more efficient and effective service. The requirements also regulate format and content standards, and establish security and privacy standards for healthcare information. The Administrative Simplification requirements apply to all covered entities, including the following: All health plans, including Medicare, Medicaid, and commercial plans Providers that transmit or store health information electronically Healthcare clearinghouses, billing services, vendors, and value-added networks (VANs) The IHCP has options available for providers to submit claims through EDI and HIPAA contentcompliant direct data entry (DDE) electronic transactions. Electronic Transaction Types Table 3.1 Electronic Transactions Processed by the IHCP Business Category Transaction Name Description Claims Processing Claims Processing Claims Processing Explanation of Payment/Remittance Advice ASC X12N 005010X222A1 ASC X12N 005010X224A2 ASC X12N 005010X223A2 ASC X12N 005010X221A1 Health Care Claim: Professional (837P) Health Care Claim: Dental (837D) Health Care Claim: Institutional (837I) Health Care Claim Payment/Advice (835) Eligibility Verification ASC X12N 005010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Claim Status ASC X12N 005010X212 Health Care Claims Status Request and Response (276/277) Prior Authorization MCE Member Enrollment Roster MCE Capitation Payment Listing ASC X12N 005010X217 ASC X12N 005010X220A1 ASC X12N 005010X218 Health Care Services Review Request for Review and Response (278) Member Benefit Enrollment and Maintenance (834) MCE Capitation Payment Listing (820) Library Reference Number: PRPR10004 3-8
Section 2: Electronic Transactions Electronic Standards HIPAA specifically names several electronic standards that must be followed when certain healthcare information is exchanged. These standards are published as National Electronic Data Interchange Transaction Set Implementation Guides, which are commonly called Implementation Guides (IGs). An addendum to most IGs was published and must be used to properly implement each transaction. The IGs are available for download through the Washington Publishing Company website at wpc-edi.com. Developers should obtain copies of the IGs prior to any process development. Companion Guides The IHCP has developed technical companion guides to assist application developers. Information contained in the IHCP Companion Guides is intended only to supplement the adopted IGs and provide guidance and clarification as the information applies to the IHCP. The IHCP Companion Guides are never intended to modify, contradict, or reinterpret the rules established by the IGs. All IHCP Companion Guides comply with the format and flow defined in the Committee for Operating Rules for Information Exchange (CORE) v5010 Master Companion Guide Template. The companion guides are available on the EDI Solutions page at indianamedicaid.com. Connectivity Options IHCP connectivity interfaces support the most commonly used channels of communication; giving clients a variety of interfaces to develop robust interchange solutions. Batch and interactive submission options are available. File Transfer Protocol Secure (FTPS) and Secure File Transfer Protocol (SFTP) options are available using: CORE compliant web services Used for batch and interactive 270/271 and 276/277transactions and 835 Remittance Advice transactions File Exchange Used for batch transactions HP Delivery and Support System (DASS) Used for interactive 270/271 and 276/277 transactions The following table identifies connectivity options available for all transactions. Transaction Table 3.2 Connectivity Options 837I Health Care Claim Institutional 837P Health Care Claim Professional 837D Health Care Claim Dental CORE Services Batch and Interactive File Exchange Batch 835 Remittance Advice (RA) X X 270/271 Eligibility Benefit Inquiry and Response DASS Direct Connection Interactive Library Reference Number: PRPR10004 3-9 X X X X X X
Chapter 3 Section 2: Electronic Transactions Indiana Health Coverage Programs Provider Manual Transaction 276/277 Claim Status Request and Response 278 Prior Authorization (PA) Request for Review and Response 834 Managed Care Member Enrollment Roster 820 Managed Care Capitation Payment Reporting CORE Web Services CORE Services Batch and Interactive File Exchange Batch DASS Direct Connection Interactive X X X The IHCP supports CORE Phase II Version 2.2.0 connectivity rules. Trading partners can submit interactive and batch 270/271 eligibility request and response transactions and 276/277 claim status inquiry request and response transactions and request outbound 835 Remittance Advice transactions via the new web service. The following interfaces are supported: Council on Affordable Quality Healthcare (CAQH) Core Phase II Simple Object Access Protocol (SOAP) + Web Services Description Language (WSDL) Interface CAQH Core Phase II Multipurpose Internet Mail Extensions (MIME) Multipart Form Interface File Exchange File Exchange is an application provided by the IHCP for secure file processing, storage, and transfer. It is designed to safely and securely collect, store, manage, and distribute sensitive information between the IHCP and its trading partners. Additional information regarding connectivity can be found in the IHCP Communications Guide, available on the Electronic Data Interchange (EDI) Solutions page at indianamedicaid.com. Note: Direct questions about submitting transactions electronically to the HP EDI Electronic Solutions Help Desk at 1-877-877-5182. Questions can also be emailed to inxixtradingpartner@hp.com. 270/271 Eligibility Benefit Inquiry and Response The 270 Eligibility Benefit Inquiry transaction is used to inquire about the eligibility, coverage or benefits associated with the IHCP under a member s benefit plan. The 271 Eligibility Benefit Response transaction is used to return information about the eligibility, coverage or benefits based on the 270 request. See Table 3.2 for methods that can be used to exchange the 270/271 transactions. See Chapter 2: Member Eligibility and Benefit Coverage for more information regarding eligibility and benefits. 3-10 Library Reference Number: PRPR10004 X X X
Section 2: Electronic Transactions 837 Health Care Claim The 837 Health Care Claim submission transaction allows providers to submit claims electronically to the IHCP. All institutional, professional, and dental claims can be entered in this manner. These claims include inpatient, outpatient, home health, long-term care, and medical, as well as Medicare crossover and Medicare Replacement Plan claims. Claims can be submitted seven days a week, 24 hours a day. See Table 3.2 for methods that can be used to submit claims. See Chapter 8: Billing Instructions and Chapter 9: IHCP Pharmacy Services Benefit for more information regarding claim submission. 276/277 Health Care Claim Status Request and Response The 276 Health Care Claim Status Request transaction is used to inquire on the status of a claim prior to the availability of the Remittance Advice (RA). The 277 Health Care Claim Response transaction is used to return claim status information based on the 276 request. See Table 3.2 for methods that can be used to exchange the 276/277 transactions. 835 Health Care Claim Payment/Advice The 835 Health Care Claim Payment/Advice transaction is available to providers that request their Remittance Advice information in an electronic format. The 835 returns information for paid and denied claims. Providers interested in receiving the 835 transaction must enroll on Web interchange in the Provider Profile Maintenance section. More information on ERA/835 enrollment can be found on Web interchange in the help documentation How to Maintain ERA/835 information under the Provider Inquiry/Maintenance Help section. See Table 3.2 for methods that can be used to retrieve the 835 transaction. See Chapter 12: Financial Services for more information regarding the 835 Remittance Advice. 278 Health Care Services Review Request and Response (Prior Authorization) Prior authorization (PA) submission allows providers to submit nonpharmacy PA requests electronically. The 278 transaction is designed to help IHCP providers file requests for PA more efficiently. See Table 3.2 for methods that can be used to exchange the 278 transaction. Library Reference Number: PRPR10004 3-11
Chapter 3 Section 2: Electronic Transactions Indiana Health Coverage Programs Provider Manual See Chapter 6: Prior Authorization for more information regarding prior authorization. Note: Managed care entities follow the guidelines for each MCE regarding the PA process. 999 Acknowledgement The 999 Acknowledgement is an X12 transaction that acknowledges the receipt of the batch transaction, and reports the acceptance or rejection of a functional group, transaction set, or segment. The 999 is available on File Exchange for trading partners approximately two hours after electronic submission between 7 a.m. and 5 p.m. to verify whether the claim file has been accepted for processing or rejected. See the 999 Acknowledgement and Submission Summary Report Guide for 999 Acknowledgement information. The companion guide is available on the EDI Solutions page at indianamedicaid.com. Submission Summary Report The Submission Summary Report (SSR) is created to report the results of pre-adjudication edit checking to verify two levels of compliance, HIPAA compliance and IHCP-specific compliance of 837D, 837I, and 837P transactions. SSRs are produced for each file received from a trading partner that contains an 837 transaction. The SSR is available on File Exchange for trading partners approximately two hours after electronic submission between 7 a.m. and 5 p.m. to verify whether the claim file has been accepted for processing or rejected. See the 999 Acknowledgement and Submission Summary Report Guide for Submission Summary Report information. The companion guide is available on the EDI Solutions page at indianamedicaid.com. 3-12 Library Reference Number: PRPR10004
Section 3: Web interchange Overview Web interchange is an interactive web application that allows providers to access the Indiana Health Coverage Programs (IHCP) system through the Internet. Web interchange is secure, fast, free, and does not require special software. Note: Pharmacy claims cannot be submitted via Web interchange. See Chapter 9: IHCP Pharmacy Services Benefit of this manual for information on pharmacy claims submittal. Web interchange Features Features of Web interchange include the following: Eligibility Inquiry Claim Submission Claim Inquiry Check/RA Inquiry Notification of Pregnancy (NOP) Inquiry Prior Authorization Submission Prior Authorization Inquiry Provider Profile View/Edit Provider Maintenance User Lists User Profile Help FAQ Providers can access Web interchange at indianamedicaid.com. System Requirements One of the following browsers should be used to access Web interchange: Internet Explorer with 128-bit encryption Internet Explorer for Macintosh is not supported. Lesser encryption values are not supported. Mozilla Firefox Google Chrome Library Reference Number: PRPR10004 3-13
Chapter 3 Section 3: Web interchange Indiana Health Coverage Programs Provider Manual Web interchange will not function properly if you are using special software that blocks pop-up windows. Users are encouraged to disable pop-up blockers when accessing Web interchange. Pop-up windows, such as the internal control number (ICN) verification of submitted claims or the temporary password assigned during the automated password reset process, will not appear if pop-up blockers are enabled. See System Requirements on the Help screen on Web interchange for more information. Web interchange Security Web interchange is Health Insurance Portability and Accountability Act (HIPAA)-compliant for direct data entry (DDE). Encryption and secured socket layer (SSL) connections protect the data in transit. HIPAA security regulations require that passwords are not shared; therefore, each user of Web interchange must have a unique user ID. Web interchange allows organizations to assign one or more administrators to oversee their members use of the website and enforces HIPAA security regulations for password usage. See System Requirements and Data Security on the FAQ screen on Web interchange for more information. Web interchange Password Regulations Web interchange password regulations meet the qualifications for HIPAA security. All passwords are case-sensitive. Web interchange users have the capability of resetting their own passwords by answering their personal reset questions. Web interchange users that contact the EDI Solutions help desk will be asked to answer his or her security questions. The EDI Solutions help desk will email a new temporary password to the user s email address on file. The user will be prompted to change the temporary password the first time he or she logs on. Users may change their passwords one time per day with the Web interchange Change Password function. Users may reset their passwords up to three times per day with the Web interchange Reset Password function. Web interchange administrators have the capability to change passwords outside these parameters. See Automated Password Reset on the Help screen and User IDs and Passwords on the FAQ screen on Web interchange for valid password formatting guidelines. Web interchange Audit Reports To protect the integrity and privacy of the information received by Web interchange users, HIPAA security requires that the IHCP audit user activity and privileges on the Web interchange site. 3-14 Library Reference Number: PRPR10004
Section 3: Web interchange Administrative Group Report The Administrative Group Report is a tool provided to all Web interchange administrators to allow them to monitor all users with access to the organization s data, the type of access given to each user, and the functions the users can perform. This report can be viewed by clicking View Group Report on the Web interchange Group Administration page. It is each administrator s obligation to review his or her report regularly. If an administrator has not reviewed the group report for 90 days, a reminder displays each time the administrator signs on to Web interchange. A button is available on the Group Report screen for administrators to click to verify that they have reviewed the report. If a group has more than one administrator, each administrator is prompted to review the report. If a person is the administrator for multiple organizations, the group report must be reviewed for each organization. Group Owner Email An email is sent every 90 days to the registered owner email address for organizations accessing Web interchange. This email contains a list of the active administrators associated with the owner s organization. The owner can verify that the list is complete and the appropriate person is the administrator for Web interchange. The owner is responsible for all actions performed by the authorized administrator within his or her organization. If an administrator leaves the organization, the owner must notify the Web interchange help desk and submit a request to establish a new administrator. Web interchange Administrator Organizations must designate a Web interchange administrator if they do not already have one. To apply for a Web interchange administrator User ID, complete the interchange Administrator Request Form. The form can be found by clicking How to Obtain an ID on Web interchange. A note on the company letterhead signed by the practice owner or highest authority with the organization approving the administrator must accompany the interchange Administrator Request Form. Mail the request form along with the letter of approval to the address shown on the form. Forms may also be faxed to (317) 488-5185. Administrators are notified via email when the application is approved. The following are the advantages and responsibilities of an administrator: Maintain compliance to HIPAA security and ensure that users do not share passwords. Create and maintain users within an organization. Users choose their own unique user ID. Reset passwords for users within an organization. Individual users can also reset their own passwords. Assign specific Web interchange access rights to users within an organization according to the user s business need. Users have access only to the information that the administrator assigns to them. Monitor users at least every 90 days to verify that the appropriate users are active and have permission to access approved information. Library Reference Number: PRPR10004 3-15
Chapter 3 Section 3: Web interchange Indiana Health Coverage Programs Provider Manual See FAQ for Web Membership on the FAQ screen of Web interchange for more information about Web interchange administrators. Eligibility Inquiry on Web interchange Eligibility Inquiry must be requested by NPI for healthcare providers. Only an atypical provider can verify eligibility by using the LPI. Access to eligibility information on members is denied if the dates of service do not fall within a provider s active IHCP program eligibility segment. Providers may search by member ID number, Social Security number, Medicare number, or name and date of birth. The response provides the same information found using the Automated Voice Response (AVR). The third-party liability (TPL) information provided includes carrier number, carrier name, address, telephone number, and policyholder name. Web interchange provides benefit limitation information. It indicates if a member has reached the benefit limits for chiropractic, dental, durable medical equipment (DME), and vision services. Benefit limitation information is based on paid claim data. Web interchange provides managed care information if the member is assigned to a managed care health plan for the time period of the eligibility request. Web interchange also allows recognized or qualified providers (QPs) access to the NOP form enabling a simplified means of communication between a member s provider and managed care entity (MCE) when a pregnancy is identified. It also permits QPs access to the Presumptive Eligibility for Pregnant Women (PEPW) or Hospital Presumptive Eligibility (HPE) application. The following information is included in the eligibility response: The Managed Care section of the response contains the MCE or care management organization (CMO) name, telephone number, primary medical provider (PMP) name, PMP telephone numbers, PMP assignment effective date and end dates based on the to and from date of service, and, if applicable, the MCE s network names. If the member has been assigned to multiple PMPs during the period of the eligibility request, the eligibility response includes each PMP and the PMP-MCE information with the date segments that the provider was assigned to the member based on the to and from date of service. If the member has been assigned to Care Select, a Care Select Notification button appears under the Managed Care section of the response. When Care Select members go to a facility for emergency room, outpatient surgery, or inpatient care services, providers can click this button and enter the date of treatment, type of service, and presenting signs, symptoms, or diagnoses. The appropriate care management organization receives and reviews the generated report on a daily basis via Web interchange and follows up with the member to ensure appropriateness and continuity of care. The NOP option is available after verifying a pregnant woman is not already enrolled in Medicaid. The Enter NOP button, displays on the NOP Begin screen. The NOP General Information screen is the NOP Form. The provider enters information, which includes the provider s information along with member s current and accurate demographics, any high-risk pregnancy indicators identified during the office visit, and basic pregnancy information. The NOP submission will help establish prenatal care for the pregnant woman and enable NOP reimbursement to the provider. Additional information about NOP can be found in Chapter 8: Billing Instructions. The PEPW or HPE application is available once the criteria for the member s eligibility has been established and verified through the NOP process. The PE Application for Pregnant Woman or HPE Application button can be selected to enroll eligible individuals to receive temporary coverage until the application is approved for IHCP by the Indiana Family and Social Services 3-16 Library Reference Number: PRPR10004
Section 3: Web interchange Administration (FSSA). Additional information about PEPW and HPE can be found in Chapter 1: General Information. See Eligibility Verification Help on the Help screen on Web interchange for more information. Claim Submission on Web interchange Claim Submission allows providers to submit individual claims electronically to the IHCP using the Internet. All institutional, professional, and dental claims, including inpatient, outpatient, home health, long-term care, and medical or waiver claims, as well as Medicare crossover and Medicare Crossover Replacement Plan claims, can be submitted electronically. On September 21, 2013, changes to the format, field length, and qualifiers/indicators for claims transactions and processes were updated to accommodate ICD-10 information. These preliminary changes were made in anticipation of the future ICD-10 implementation. Entry of ICD-10 information on claims is not required until the implementation date. A claim submitted through Web interchange is assigned an ICN and available for viewing through claim inquiry approximately two hours after submission. See Chapter 8: Billing Instructions of this manual for claim billing instructions. The Claim Submission screen on Web interchange also contains a link to Clear Claim Connection, a web-based solution that enables HP and the FSSA to share with providers the claim auditing rules and clinical rationale associated with the National Correct Coding Initiative (NCCI). Note: Providers cannot use Web interchange to submit claims to managed care entities. Web interchange may not be used for submitting pharmacy claims to the IHCP. See Claim Submission Help on the Help screen and FAQ for Transactions on the FAQ screen on Web interchange for more information. Voids and Replacements on Web interchange Note: See Chapter 9: IHCP Pharmacy Services Benefit of this manual for information regarding pharmacy claim voids and replacements for point-ofsale or paper. Providers are able to submit an electronic void or replacement for a previously submitted claim in a paid status. A void or replacement can be completed on the same day or in the same week as a claim submission or after the payment is finalized. However, when performing an electronic void of a claim that was subject to NCCI auditing, providers must wait until the following day to resubmit a claim related to the voided claim. Resubmitting claims that are related to a voided claim applies only to non-check-related replacements; however, it applies to pre-financial and post-financial claims. New region codes are assigned to postfinancial claims for electronic voids or replacements. Library Reference Number: PRPR10004 3-17
Chapter 3 Section 3: Web interchange Indiana Health Coverage Programs Provider Manual See Claim Submission Help on the Help screen on Web interchange for more information on submitting electronic voids and replacements. Coordination of Benefits Information in Web interchange Coordination of benefits (COB) information can be submitted for crossover, crossover Medicare Replacement Plan, and TPL claims on Web interchange. See Claim Submission Help on the Help screen and FAQ for Transactions on the FAQ screen on Web interchange for more information about coordination of benefits. See Chapter 8: Billing Instructions of this manual for claim billing instructions. See Chapter 5: Third Party Liability and Chapter 10: Claims Processing Procedures of this manual for crossover claim processing procedures. User Lists on Web interchange User Lists are created to help a user store and retrieve frequently used data, such as Member ID, rendering provider number, diagnosis codes, and modifiers. This capability eases the process of submitting claims and prior authorizations. Data entered via a User List is not validated against IHCP data for accuracy. It is the responsibility of the user to maintain any data stored in a User List. Any data entered in this User List may be analyzed by HP to ensure validity. See Claim Submission Help on the Help screen on Web interchange for more information on user lists. Claim Inquiry on Web interchange Claim Inquiry allows providers to inquire about previously submitted claims, even before they appear on the Remittance Advice (RA) summary or 835 transaction. Claims submitted electronically are accessible within two hours and remain accessible for seven years. However, due to the NCCI claim editing, it is possible that claims may not be accessible in Web interchange within the normal twohour time frame. Providers may contact HP Customer Assistance if claims are not accessible within 24 hours. Claims are located by searching within a date range, by claim type, by member ID, or by ICN. When the basic claim information displays, click the desired claim ICN for more detail. In keeping with HIPAA privacy requirements, built-in security features allow only billing providers to view the claims they submitted. Note: Web interchange cannot be used to view the status of claims submitted to managed care entities. See Claim Inquiry Help on the Help screen on Web interchange for more information. 3-18 Library Reference Number: PRPR10004
Section 3: Web interchange Check/RA Inquiry on Web interchange Check/RA Inquiry allows the provider to inquire about previously received payments. A list of checks, electronic funds transfers (EFTs), and RAs can be found by searching within the date range or by searching for a specific check number. When the basic check information displays, click on that line to obtain a list of all claims associated with that check. The link to download the RA displays regardless of check availability. If no check was issued in conjunction with the RA, the check number displays as 000000000. Providers are encouraged to print RAs weekly or save them to their system for future reference. Note: A rolling 12 weeks of RAs are available. In keeping with HIPAA privacy requirements, built-in security features allow only billing providers to view the checks and RAs they have received. See Check Inquiry Help on the Help screen on Web interchange for more information. NOP Inquiry on Web interchange NOP Inquiry allows the provider to search for a previously submitted NOP. The NPI/LPI used to enter the NOP via member eligibility must be the same NPI or LPI used for the NOP Inquiry function. The appropriate service location will need to be selected if the NPI is associated with more than one LPI. The provider can search for all NOPs, a specific NOP, or by the member identification number (RID), member name, or member Social Security number. Prior Authorization Submission on Web interchange Note: Requests for drugs, such as nonpreferred medications and the Medical Necessity Review Form for mental health medications, cannot be submitted via the Web. See Chapter 9: IHCP Pharmacy Services Benefit of this manual for information regarding pharmacy PA. Web interchange Prior Authorization Submission allows providers to submit PA requests electronically through the Internet. This tool is designed to help IHCP providers file PAs faster and more easily. Even though a PA request is submitted through the Internet, the rules for making PA decisions still follow the same 10-day time line. Providers should be specific, clear, and concise on all PA requests to avoid PA suspensions. All information required for paper PA submissions is also required for Web submissions. As specified in Indiana Administrative Code (IAC) citations 405 IAC 5-3-10, 405 IAC 5-30-4, and 405 IAC 5-34-11, the providers that may submit PA requests are as follows: Doctor of medicine Doctor of osteopathy Dentist Optometrist Podiatrist Chiropractor Library Reference Number: PRPR10004 3-19
Chapter 3 Section 3: Web interchange Indiana Health Coverage Programs Provider Manual Home health agency Hospital Hospice Psychologist endorsed as a health service provider in psychology (HSPP) Transportation providers (authorized agents) Note: DME providers cannot submit PA requests via Web interchange. See Prior Authorization Submission Help on the Help screen on Web interchange for more information. Prior Authorization Inquiry on Web interchange PAs submitted electronically during business hours are viewable within two hours of submission. PAs can be located by using the search fields of Service Location, Member ID, Procedure Code, Modifiers, Revenue Code, Service Date, and Assignment Code. Providers can inquire about PA for any known prior authorization number or confirmation number. See Prior Authorization Inquiry Help on the Help screen on Web interchange for more information. Provider Profile on Web interchange The Provider Profile enables providers to view their IHCP profile information. Accessing the Provider Profile function allows providers to view information on file with the IHCP, including name, current addresses and telephone numbers, type and specialties, license number, Clinical Laboratory Improvement Amendments (CLIA) information, Medicare number, EFT information, tax identification number information, and PMP managed care information. Groups are also able to view all the rendering providers associated with the practice. Copies of the Provider Profile can be printed from Web interchange. Provider profile updates that do not require supportive documentation can be made through Web interchange quickly, easily, and securely without submitting paper forms. For example, users who have appropriate permissions can change the address or bank account information for EFT and set up the provider for the 835 electronic remittance transaction. Examples of changes that cannot be made online include changing a primary specialty, which requires certification, or changing the home office address or legal name, which requires a new W-9 form. Terminations cannot be made online because of managed care PMP considerations. For example, an accidental termination could result in the loss of a PMP s assigned patient panel, causing confusion for members. Provider Profile gives access to PEPW and HPE providers to enroll as a QP by completing the presumptive eligibility information on the Presumptive Eligibility tab located on the Provider Maintenance window. The Provider Profile update function is available to any user within the provider s organization who has been granted Provider Maintenance access by his or her Web interchange administrator. It is the administrator s responsibility to provide Edit access to only the appropriate users. By limiting 3-20 Library Reference Number: PRPR10004
Section 3: Web interchange personnel who have access to this function, administrators can prevent unauthorized changes to the profile. Administrators should also ensure that users do not share their user IDs and passwords. Access to a specific function is user-id specific and is available to anyone using that ID and password. The Provider Profile screen also contains a link for eligible hospitals (EH) and eligible professionals (EP) to register for the Indiana Medicaid Electronic Health Record (EHR) Incentive Program. See Provider Inquiry/Maintenance Help on the Help screen on Web interchange for more information. User Profile on Web interchange User Profile is available to all Web interchange users and allows users to update various basic information about the owner of the ID, including telephone number, email address, and user-specific security questions and answers. See Profile Maintenance Help on the Help screen on Web interchange for more information. If you have questions about accessing Web interchange, contact the HP EDI Solutions Help Desk tollfree at 1-877-877-5182. Questions can also be sent by email to INXIXElectronicSolution@hp.com. For claims questions, contact the HP Customer Assistance Help Desk toll-free at 1-800-577-1278. Library Reference Number: PRPR10004 3-21
Section 4: Electronic Data Interchange Trading Partner Process Overview The Health Insurance Portability and Accountability Act (HIPAA) requires all healthcare organizations exchanging HIPAA transaction data electronically with the Indiana Health Coverage Programs (IHCP) establish an electronic data interchange (EDI) relationship. Entities with this EDI relationship are referred to as trading partners. The IHCP has prepared the information in this section to assist entities with becoming IHCP trading partners. Trading partners with the IHCP have options for transmitting data electronically. See Electronic Transactions section for more information. Trading Partners A trading partner is defined as an entity sending and/or receiving data with another entity electronically. The following are examples of a trading partner: Provider using approved vendor software Clearinghouse Billing service Managed care entity (MCE) Medicare intermediary or carrier Value-added network (VAN) (interactive transactions only) Trading partner information is available on the EDI Solutions page at indianamedicaid.com. Providers Not Required to Become an IHCP Trading Partner Providers that exchange data with the IHCP exclusively using the following methods do not need to become IHCP trading partners: Providers using a clearinghouse that has been approved by the IHCP Providers using a VAN that has been approved by the IHCP Providers using Web interchange Providers using the Automated Voice Response (AVR) Trading Partner Procedures IHCP providers desiring to exchange data directly to or from the IHCP must use an approved software vendor or clearinghouse. HP works with many software vendors throughout the United States and has created a list of approved software vendors that provide HIPAA-compliant billing and software services to the IHCP provider community. There is no affiliation between HP and any of these Library Reference Number: PRPR10004 3-22
Section 4: Electronic Data Interchange Secure File Transfer Protocol companies. It is the responsibility of the provider to select the vendor based on specific business needs. A list of approved software vendors is available on the EDI Solutions page at indianamedicaid.com. Providers developing their own software must follow the Software Testing Procedures before becoming a trading partner. Providers interested in programming software for sending claims electronically should review the trading partner testing information on the EDI Solutions page at indianamedicaid.com. Trading Partner Profile The IHCP requires that entities requesting to become a trading partner with the IHCP complete and electronically submit the IHCP Trading Partner Profile. The IHCP Trading Partner Profile is the tool used to notify the IHCP about the types of transactions they will exchange. Software vendors and clearinghouses requesting a Trading Partner ID to test their software should choose the Vendor/Clearinghouse profile. Providers and clearinghouses requesting a Trading Partner ID to exchange production transactions should use the Provider profile. Production IDs will not be assigned until the software for the transaction type has been tested and approved. After the initial Trading Partner ID setup, the IHCP Trading Partner Profile is used to inform the IHCP of any contact information or software vendor changes. The IHCP Trading Partner Profile is available on the EDI Solutions page at indianamedicaid.com. SoftwareTesting Process Vendors must review the X12N transaction HIPAA Implementation Guides (IGs) and the IHCP Companion Guides to carefully assess the changes needed to their business and technical operations to meet the requirements of HIPAA. The national X12N transaction HIPAA implementation guides are available on the Washington Publishing Company website at wpc-edi.com. The IHCP Companion Guides link takes you to the current production versions of the guides, and the IHCP Upcoming Companion Guide Changes contains future system updates to the guides. Software vendors, clearinghouses, VANs, and MCEs seeking approval of their software products should follow the Software Testing Process. The testing process may take several days or weeks, depending on the organization s experience with EDI. Complete the Trading Partner Profile The IHCP requires each testing entity to complete and submit the IHCP Trading Partner Profile to initiate the testing process. The IHCP Trading Partner Profile is the tool the vendor must use to notify the IHCP about the types of transactions they request to test and the method of communication they will use. When the IHCP receives the profile, testing information is sent to the vendor. Follow the instructions received in the testing information to ensure accuracy and completeness of testing. Library Reference Number: PRPR10004 3-23
Chapter 3 Indiana Health Coverage Programs Provider Manual Section 4: Electronic Data Interchange Secure File Transfer Protocol Conduct Application Development Test The vendor must modify its business application systems to comply with the IHCP Companion Guides. Accuracy of the vendor s software must be tested to ensure all transactions process correctly. The vendor must determine the modifications and additions its technical infrastructure needs to perform and support communication functions. Three levels of testing are required: Connectivity testing Compliance/Validation testing End-to-End testing Connectivity Testing Connectivity testing is performed with the transmissions to ensure a successful connection between the sender and receiver of data. Compliance/Validation Testing All transactions must pass data integrity, requirements, balancing, and situational compliance testing. Although third-party HIPAA certification is not required, the preceding levels of compliance are required and must be tested. Compliance is accomplished when the transaction is processed without errors and a 999 Acknowledgement is produced. Validation testing ensures conformity to the IHCP Companion Guides. This testing ensures that the segments or records that differ based on certain healthcare services are properly created and produced in the transaction data formats. Validation testing is unique to specific relationships between entities and includes testing of field lengths, output, security, load/capacity/volume, and external code sets. End-to-End Testing End-to-end testing ensures a successful round-trip completion of the transmission. It originates from the sender as an inbound transaction, proceeds through system processing and ends with a successful outbound transaction back to the sender. For example, for vendors set up to test the 837 and 835 transactions, this level tests processing the inbound 837 Claims and Encounters transactions and follows through to create an outbound 835 Remittance Advice transaction. Testing information is available on the EDI Solutions page at indianamedicaid.com. Software Approval Process The approval process differs slightly for software vendors, clearinghouses, and VANs. Software Vendor HP emails approval to the testing vendor on completion and approval of testing. Vendors should inform providers using their software that they have completed testing. The provider must complete 3-24 Library Reference Number: PRPR10004
Section 4: Electronic Data Interchange Secure File Transfer Protocol and submit the IHCP Trading Partner Profile and signed IHCP Trading Partner Agreement. On receipt, the IHCP sends the provider a trading partner ID, logon information, and secure FTP information. Clearinghouse, Value Added Network, Managed Care Entity When testing and approval are complete, the IHCP sends email notification of approval to the clearinghouse, VAN or MCE. On receipt of this approval, the clearinghouse, VAN or MCE is required to complete the procedures outlined in the Production Trading Partner Enrollment Process to get production submission credentials and information. Production Trading Partner Enrollment Process Entities that directly exchange production data electronically with the IHCP must become IHCP trading partners by completing the following tasks. Complete a Trading Partner Profile The IHCP requires entities exchanging production data directly with the IHCP to complete and submit the IHCP Trading Partner Profile to initiate the process for becoming a trading partner. The IHCP Trading Partner Profile is the tool providers and clearinghouses must use to notify the IHCP about the types of transactions they request to exchange and the software they will use. The IHCP Trading Partner Profile is also used to inform the IHCP of any changes to their vendor software or contact information. Complete a Trading Partner Agreement The IHCP Trading Partner Agreement is a contract between parties that have chosen to become electronic business partners. The IHCP Trading Partner Agreement stipulates the general terms and conditions under which the partners agree to exchange information electronically. If entities initially exchange multiple transaction types electronically, only one signed IHCP Trading Partner Agreement is required. A new IHCP Trading Partner Agreement is required when requesting to add additional transaction types at a later date. Electronic signature is acceptable. The IHCP Trading Partner Agreement can be returned in these manners: Complete and send via email to INXIXTradingPartner@hp.com or Print, sign, and mail to the following address: HP Enterprise Services Trading Partner Agreement 950 North Meridian Street Suite 1150 Indianapolis, IN 46204 Upon receipt of the IHCP Trading Partner Profile and the signed IHCP Trading Partner Agreement, the entity will be evaluated for exchanging production data. The trading partner will receive email notification of approval, which will include logon credentials. Library Reference Number: PRPR10004 3-25