11 west forty-second new york, ny 10046 www.empireblue.com DATE: July 2003 AUDIENCE: Institutional Electronic Claims Submitters SUBJECT: Electronic Media Claims (EMC) Receipt Report for 837 Institutional Claims Transmissions EMCD6102-01 for Production Claim Transmissions EMCD6102-11 for New Biller Test Claim Transmissions EMCD6102-03 for Unknown Receiver Production Claims EMCD6102-13 for Unknown Receiver New Biller Claims IMPORTANT INFORMATION: A new EMC front-end receipt report has been developed to report the results of the front-end validation of all X12 837 claim transmissions. The new report numbers are: EMCD6102-01 for PRODUCTION transmissions EMCD6102-11 for NEW BILLER test transmissions EMCD6102-03 for Unknown Receiver Production Claims EMCD6102-13 for Unknown Receiver New Biller Claims The third line of the heading on the report will identify the line of business Blue Cross. If we are unable to determine the line of business due to an invalid receiver ID in ISA07, a value of UNKNOWN will be present for the line of business. The report heading will contain a fourth line if the transmission is a New Biller test, in addition to having a different report number. and Blue Shield Plans.
There are five levels of validation performed in the EMC front-end system. See Bulletin EMC2003-02BC for details on editing. The EMC Receipt Report provides a status of each level described below: Level 1 ISA Edits Level 2 X12 997 Functional Acknowledgement (Standard Syntax) Level 3 GS Edits Level 4 Implementation Guide (IG) Edits Level 5 Empire Business Edits In addition to the above editing, Empire creates a TA1 acknowledgment and reports the results on the receipt report. If any errors are received, they are reported under the Transmission Summary section of the report. The standard error messages are used and are documented in section B (Interchange Acknowledgement) section in the implementation guides. Refer to element TA105. The report will be available for retrieval approximately two hours after a claim transmission is received by Empire. The EMC Receipt Report must be printed landscape. The report is available for retrieval via Empire e-link, Connect Direct, TCP/IP-FTP and NJE as follows: Empire e-link: Click on Get Files and then click on EMC Receipt Reports. Connect Direct and TCP/IP-FTP filenames available for retrieval: Production: emc.d364h.d6102.curhh emc.d364h.d6102.curhh.zip emc.d364h.d6102.xzyymmdd New Biller test: uemc.d364h.d6102.curhh uemc.d364h.d6102.curhh.zip uemc.d364h.d6102.xzyymmdd NJE: Please contact your Institutional EDI Representative to discuss JCL requirements. Syracuse: Sue Benz 315 442-4780 Marge Regan 315 442-4833 Albany: Robert Snyder 518 367-3107 New York City: Victor Martin 212 476-1206 and Blue Shield Plans.
Attachment 1 contains the following information on the EMC Receipt Report: Control Numbers Report Layout Data Dictionary detailed description of each field on the Receipt Report Report Examples pass and fail conditions for the different levels of EMC validation 837 submitters will not receive the long confirmation or the EMCD6110 Submission Validation report. The EMCD6102 replaces these reports for 837 submissions. Note: All current EMC reports will continue to be supported for UB92 and 837 pre-4010 version until October 16, 2003. Effective October 16, 2003, the X12 837 version 4010A1 will be the only electronic claim format accepted. CUSTOMER SUPPORT Monday through Friday Contact Hours Available Telephone Fax Number Internet Address Number IES Technical Help Desk 8:30A.M. 4:30P.M. 1-866-889-7322 1-416-774-4778 www.empireblue.com and Blue Shield Plans.
Attachment 1 Blue Cross Receipt Report (EMC 2003-03BC) and Blue Shield Plans.
Control Numbers EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 Empire Entry Control Number (ECN) EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C 0235200037S VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER SUBMITTER ID ID (ISA06): (ISA06): 123456789 123456789 TRANSMISSION STATUS: REJECT Interchange Control Number (ISA13) MEDICAL FACILITY NAME CONTACT PERSON NAME 123 MAIN ST Submitter ID (ISA06) ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY SUBMITTER ID ID (ISA06): 123456789 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP GROUP CONTROL NUMBER (GS06): 100 1001 GS IG LEVEL EDITS: PASSED Application Receiver Code (GS03) Group Control Number (GS06) Control Numbers There are several control numbers on this report that are critical when reviewing transmissions. Some control numbers are in the transmission, others are assigned by the EMC front-end system. It is important that you are able to locate these control numbers on the report. Control Number Source ISA13 Interchange Control Number 837 transmission ISA06 Submitter ID 837 transmission GS03 Application Receiver Code 837 transmission GS06 Group Control Number 837 transmission ST02 Transaction Set Control Number 837 transmission (next page) Empire Entry Control Number (ECN) Assigned by Empire Empire Submission Control Number Assigned by Empire (next page) Blue Cross Receipt Report 1
Control Numbers EMCD6102-01 EMPIRE 123456789 C PAGE: 2 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C VERSION (GS08): 004010X096A1 These control numbers are INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 repeated on every page. TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 1001 TRANSACTION SET CONTROL NUMBER (ST02): 000000001 CLAIMS EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 23520221C CLAIMS CLAIMS PASSED TO TRANSACTION STATUS: FAILED RECEIVED REJECTED ADJUDICATION SEGMENT COUNT (ST/SE): 36 1 1 0 ---------- ERROR KEY ---------- ERROR CODE ERROR MESSAGE IGE0000005 ICD-9-CM PROCEDURE CODE ENTERED IS INVALID IGE0000004 HCPCS/CPT4 CODE ENTERED IS INVALID Group Control Number (GS06) Empire Submission Control Number Transaction Set Control Number (ST02) Control Numbers These control numbers are repeated on every page for this transaction (ST / SE). There are several control numbers on this report that are critical when reviewing transmissions. Some control numbers are in the transmission, others are assigned by the EMC front-end system. It is important that you are able to locate these control numbers on the report. Control Number Source ISA13 Interchange Control Number 837 transmission ISA06 Submitter ID 837 transmission GS03 Application Receiver Code 837 transmission (previous page) GS06 Group Control Number 837 transmission ST02 Transaction Set Control Number 837 transmission Blue Cross Receipt Report Empire Entry Control Number (ECN) Assigned by Empire Empire Submission Control Number 2 Assigned by Empire
Report Layout REPORT LAYOUT The examples on the following pages provide a detailed description of the EMC Receipt Report layout. See the Data Dictionary for specific fields displayed on the EMC Receipt Report. The EMC Receipt Report (EMCD6102-01 and EMCD6102-11) must be printed landscape. Blue Cross Receipt Report 3
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C VERSION (GS08): The page number 004010X096A1 starts at 1 for INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION each MODE: ISA through E-LINK IEA. SUBMITTER ID (ISA06): 123456789 TRANSMISSION STATUS: REJECT MEDICAL FACILITY NAME CONTACT PERSON 123 MAIN ST ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY Heading Section The Heading Section appears on the top of every page. The third line of the heading indicates the line of business. The lines of business are: Blue Cross and Unknown. SUBMITTER ID (ISA06): 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 1001 GS IG LEVEL EDITS: PASSED The report number EMCD6102-01 indicates Production. If this submission is a New Biller test, the report number will be EMCD6102-11. Blue Cross Receipt Report 4
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 Each new ISA through IEA EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C resets the page number to VERSION one. (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 TRANSMISSION STATUS: REJECT MEDICAL FACILITY NAME CONTACT PERSON 123 MAIN ST ANYTOWN NY 12345 Control Section * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 1001 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY The Control Section lists transmission related data. This section appears for each new ISA through IEA segments. GS IG LEVEL EDITS: PASSED Blue Cross Receipt Report 5
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 TRANSMISSION STATUS: REJECT MEDICAL FACILITY NAME CONTACT PERSON 123 MAIN ST ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * Broadcast Message Section TRANSMISSION SUMMARY INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 1001 GS IG LEVEL EDITS: PASSED FUNCTIONAL GROUP (GS/GE) SUMMARY The Broadcast Message Section will only appear if there is a broadcast message. This message is used to give the submitter important information such as critical news items, cycle problems, or printing problems. Blue Cross Receipt Report 6
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C This section appears for a new ISA through VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 000000004IEA, which causes the page number to reset TRANSMISSION to MODE: E-LINK SUBMITTER ID (ISA06): 123456789one. The Transmission Summary section TRANSMISSION will STATUS: REJECT always appear below the Control Section on MEDICAL FACILITY NAME CONTACT PERSON NAME page 1. 123 MAIN ST ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 1001 GS IG LEVEL EDITS: PASSED TRANSMISSION SUMMARY Transmission Summary FUNCTIONAL GROUP (GS/GE) SUMMARY The Transmission Summary section is identified by its heading. This section provides the status of the Interchange Control Header (ISA) Edits and indicates if the 997 Standard Level Edits were performed. If any ISA level edits or TA1 messages are received, they are printed in this section. Blue Cross Receipt Report 7
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 1 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 The first functional group in the ISA through IEA is EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C printed on page 1 following the Transmission VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 000000004 Summary. Every new functional group after that TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 TRANSMISSION STATUS: will start a new page. The page number for the REJECT MEDICAL FACILITY NAME new functional group is the next sequential page CONTACT PERSON NAME number. The page number does not reset to one. 123 MAIN ST ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY SUBMITTER ID (ISA06): 123456789 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 1001 GS IG LEVEL EDITS: PASSED Function Group Summary The Functional Group Summary section is identified by its heading. This section applies to the functional group identified by the Group Control Number. The Group Control Number is the value in the 837 GS06. If any GS level edits are received, they are printed in this section. Blue Cross Receipt Report 8
Report Layout EMCD6102-01 Each transaction EMPIRE (ST through SE) will start a new page. The 123456789 page C PAGE: 2 RUN DATE: 12/18/02 number ELECTRONIC for the new MEDIA transaction CLAIMS is the next sequential page CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT number. The page number does not reset to one. RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C VERSION (GS08): 004010X096A1 This control information is printed on INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 every new page for easy reference. TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 1001 TRANSACTION SET CONTROL NUMBER (ST02): 000000001 Transaction Summary CLAIMS EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 23520221C CLAIMS CLAIMS PASSED TO TRANSACTION STATUS: FAILED RECEIVED REJECTED ADJUDICATION SEGMENT COUNT (ST/SE): 36 1 1 0 ---------- ERROR KEY ---------- ERROR CODE ERROR MESSAGE IGE0000005 ICD-9-CM PROCEDURE CODE ENTERED IS INVALID IGE0000004 HCPCS/CPT4 CODE ENTERED IS INVALID Error Key The Error Key is printed whenever the transaction (ST through SE) has any errors. The Error Key lists all error codes found in the transaction and the corresponding error messages. The Error Key will only appear if there are any errors in the transaction. The Transaction Summary section is identified by its heading. This section applies to the transaction (ST through SE) identified by the Transaction Set Control Number. This Transaction Set Control Number is the value in the 837 ST02. This section indicates the status of the transaction. It displays the number of claims received, the number of claims rejected due to errors, and the number of error-free claims passed to adjudication. If there are any transaction level errors, they will be printed following the Error Key. Blue Cross Receipt Report 9
Report Layout This section begins on a new page for each provider. EMCD6102-01 EMPIRE 123456789 C PAGE: 2 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037C VERSION (GS08): 004010X096A1 This information is printed on each new INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 page for easy reference to tie multiple TRANSMISSION STATUS: REJECT GROUP CONTROL NUMBER (GS06): 1001 functional groups and transaction sets TRANSACTION SET CONTROL NUMBER (ST02): 000000001 together. EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 23520221C PROVIDER (HL03=20) SUMMARY PROVIDER: ABCD123456789 MEDICAL PROVIDER INC Provider Summary CLAIMS CLAIMS CLAIMS PASSED TO RECEIVED REJECTED ADJUDICATION 5 0 5 MESSAGE0004 NO ERRORS FOR THIS PROVIDER This message indicates there are no provider level errors, and no subscriber, dependent or claim level errors for this provider. The Provider Summary section is identified by its heading. This section applies to the Provider identified by the Provider Number and Name. The Provider Number is the value in Loop 2010AA REF02. The Provider Name is from an Empire internal control file. This section indicates the status of the provider and the claims submitted by the provider. If there are any provider level errors, in Loops 2000A, 2010AA and 2010AB, those errors will be listed in this Provider Summary section. The claim counts are for all subscriber and dependent claims submitted for this provider. If the subscriber, dependent or claims have any errors, these errors will be listed in another section of the report the Provider Detail section. Blue Cross Receipt Report 10
Report Layout EMCD6102-01 EMPIRE 123456789 C PAGE: 2 RUN DATE: 12/18/02 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 12/17/02 RUN TIME: 11:31:51 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 10/01/02 EMPIRE ENTRY CONTROL NUMBER (ECN): 0235200037S VERSION (GS08): 004010X096A1 This information is printed on each new INTERCHANGE CONTROL NUMBER (ISA13): 000000004 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 123456789 page for easy reference to tie multiple TRANSMISSION STATUS: REJECT GROUP CONTROL NUMBER (GS06): 1001 functional groups and transaction sets TRANSACTION SET CONTROL NUMBER (ST02): 000000001 together. EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 23520221S PROVIDER (HL03=20) SUMMARY PROVIDER: ABCD123456789 MEDICAL PROVIDER INC CLAIMS CLAIMS CLAIMS PASSED TO RECEIVED REJECTED ADJUDICATION 7 7 0 Provider Detail PROVIDER (HL03=20) DETAIL SEGMENT/ MEMBER ID#/ LAST NAME, FI/ ERROR ERROR ELEMENT/ PAT CNTL# STATEMENT DATE LEVEL CODE LOOP ID QUALIFIER INPUT DATA SUBSCRIBER: 085268312 ANNONE, R SUBSCRIBER BC00000113 2010BA NM109 /IL 111333555999 2010BC NM109 /PR 00303 CLAIM: 1A-1 PROFPOSTEST 20020506 CLAIM IG0027 2400 LX01 /4 4 CLAIM: 1A-2 PROFPOSTEST 20020506 CLAIM BC00000049 2300 HI01-2 /BE 01 2300 HI01-5 /BE 0 CLAIM: 1A-1 PROFPOSTEST 20020506 CLAIM IG0027 2400 LX01 /4 4 CLAIM: 1A-2 PROFPOSTEST 20020506 CLAIM BC00000049 2300 HI01-2 /BE 01 2300 HI01-5 /BE 0 PATIENT: PANNONE, L CLAIM: 1AX-1 PROFPOSTEST 20020507 CLAIM AK4037 2300 REF01 /01 01 CLAIM: 1AX-2 PROFPOSTEST 20020507 CLAIM IG0027 2400 LX01 /4 4 SUBSCRIBER: 085268312 PANNONE, R SUBSCRIBER BC00000113 2010BA NM109 /IL 111333555999 2010BC NM109 /PR 00303 CLAIM: 1B-1 PROFPOSTEST 20020508 REJECTED DUE TO SUBSCRIBER LEVEL ERRORS MESSAGE005 END OF REPORT FOR TRANSACTION SET CONTROL NUMBER 000000001 The Provider Detail section is identified by its heading. This section applies to the Provider listed in the Provider Summary section. This section lists subscriber, dependent and claim level errors. If a claim has no errors but is rejected due to an error occurring at it s associated dependent or subscriber, the claim is listed with a message indicating it is rejected due to a higher level error. Blue Cross Receipt Report 11
Data Dictionary DATA DICTIONARY This is a description of each field on the EMC Receipt Report. Fields are listed in alphabetic order. Field Name Values / Format Description Application 2-15 characters This is the value submitted in the 837, GS03. Receiver s Code (GS03) Broadcast Message 240 characters This message is used to alert submitters of critical information such as news items, cycle problems, printing problems. It functions in the same manner as the current EMCD6110 Report broadcast message. This message will only appear on page 1 above the Transmission Summary section of the report. It is enclosed in a rectangle of asterisks * for quick identification. Claims Received (Transaction ST-SE Level) Claims Rejected (Transaction ST-SE Level) Claims Passed to Adjudication (Transaction ST-SE Level) Numeric Numeric Numeric If there is no message, nothing is printed. This total is calculated by the EMC front-end system and is the total number of claims within the ST through SE received. When a critical error is received, claim counts will be reported up to where the error occurred. Please refer to the edit documentation for the critical errors. This total is calculated by the EMC front-end system and is the total number of claims for the entire ST through SE rejected. When a critical error is received, claim counts will be reported up to where the error occurred. Please refer to the edit documentation for the critical errors. This total is calculated by the EMC front-end system and is the total number of claims for the entire ST through SE passed to the claims processing system for adjudication. When a critical error is received, claim counts will be reported up to where the error Blue Cross Receipt Report 12
Data Dictionary Field Name Values / Format Description occurred. Please refer to the edit documentation for the critical errors. Claims Received (Provider Level) Numeric This total is calculated by the EMC front-end system and is the total number of claims for the specific provider (HL03=20) received in the front-end system. Claims Rejected (Provider Level) Claims Passed to Adjudication (Provider Level) Numeric Numeric When a critical error is received, claim counts will be reported up to where the error occurred. Please refer to the edit documentation for the critical errors. This total is calculated by the EMC front-end system and is the total number of claims for the specific provider (HL03=20) rejected in the front-end system. When a critical error is received, claim counts will be reported up to where the error occurred. Please refer to the edit documentation for the critical errors. This total is calculated by the EMC front-end system and is the total number of claims for the specific provider (HL03=20) passed to the claims processing system for adjudication. When a critical error is received, claim counts will be reported up to where the error occurred. Please refer to the edit documentation for the critical errors.. Cycle Date MM/DD/YY This is the date of the next production cycle planned for the EMC front-end system. Empire Entry Control Number (ECN) YYDDD*****X The actual receipt date will be retained and reported in the Receipt Date field. This is the EMC front-end system assigned control number for the entire ISA through IEA. This is a unique number and is never repeated within the EMC front-end system. The ECN is assigned by Empire for each ISA through IEA received and is Empire s control number. The 837 submitter populates ISA13 on the 837 with their control number for the entire transmission (ISA through IEA). Format: Blue Cross Receipt Report 13
Data Dictionary Field Name Values / Format Description 2 position Year (YY) 3 position Julian Day (DDD) 5 position Sequence Number (*****) 1 position Line of Business (X) C Blue Cross U Unknown Empire Submission Control Number (ST/SE) Error Code Error Level YDDD**** Transaction Provider Unknown will be present when data in the ISA is invalid and the Line of Business cannot be determined. This is the EMC front-end system number generated for each ST through SE within an ISA through IEA. This is a unique number for each ST through SE and is never repeated within the EMC front-end system. An Empire Submission Control Number is generated by Empire for each ST through SE that passes ISA and 997 levels of validation. The 837 submitter populates ST02 in the 837 with their control number for the ST through SE. Format: 1 Position Year (Y) 3 Position Julian Day (DDD) 4 Position Sequence Number (****) 1 Position Line of Business (C,U) C Blue Cross U Unknown Unknown will be present when the Line of Business cannot be determined. This is the EMC front-end system error code. There are five levels of errors where implementation guide or business edits can be received. Blue Cross Receipt Report 14
Data Dictionary Field Name Values / Format Description Subscriber Transaction The entire ST through SE is rejected. Patient Provider - The entire provider Hierarchical Level (HL03=20) is rejected. Claim Subscriber All claims associated with a specific subscriber (HL03= 22) are rejected. This includes claims for the subscriber and patients associated with the subscriber. Patient All claims associated with a specific patient (HL03= 23) are rejected Claim A specific claim is rejected. Error Key The Error Key section is reported on the Transaction Summary section of the report. It is a listing of all error codes within the St through SE. The narrative description is displayed for each error code. Error Message This is the description of the EMC front-end system error code. FI (First Initial) 1 Position This is the first initial of the first name for the subscriber or patient. Group Control Number (GS06) This is the value submitted in the 837, GS06. GS IG Level Edits Passed Failed If any GS edits are received, they are displayed under the Group Control Number. Editing of the ST through SE s within the GS through GE will stop. No reporting is done on any of the ST through SE s within the rejected GS through GE. Passed The literal Passed is generated for each GS through GE that passes the GS IG level edits. Not Performed Failed The literal Failed is generated for each GS through GE that fails a GS IG level edit. The error message is displayed. The submitter must correct and resubmit the entire GS through GE. Not Performed The literal Not Performed is generated for each GS through GE that fails the 997 edits. Blue Cross Receipt Report 15
Data Dictionary Field Name Values / Format Description The submitter must correct and resubmit the entire GS through GE. Input Data 17 characters A maximum of 17 characters of the input data in a specific segment or element is displayed when an error occurs. Interchange Control Header Edits (ISA) Passed Failed These are EMC front-end system edits performed against the Interchange Control Headers (ISA) and control files. Each ISA through IEA receives an Empire Entry Control Number (ECN) and generates a separate EMC Receipt Report. The page number starts with 1 and increments by 1 until the next ISA through IEA. Passed The transmission passes the interchange control header edits. The file will then be passed to the translator and processing continues. Failed The transmission fails the interchange control header edits. Any interchange control header edits received are listed on the Transmission Summary. Processing stops and the file is not passed to the translator. The submitter must correct and resubmit the entire ISA through IEA. No other sections of the report are populated. 999999999 This is the value submitted in the 837, ISA13. Interchange Control Number (ISA13) Last Name 20 Positions This is last name of the subscriber or patient. Loop ID Defined in the 837 Implementation guide. This is populated by the EMC front-end system when available and identifies the loop where the error occurred. Member ID # 20 Positions This is the identification number for the subscriber or the patient. It is on the claim. Message Display Message There are messages displayed on the report to help clarify the status at different levels Number and of the report. These are informational messages and not specific error codes. The Blue Cross Receipt Report 16
Data Dictionary Field Name Values / Format Description Narrative messages have a number and narrative and begin with MESSAGE followed by three numeric positions. For example, MESSAGE001. Refer to Bulletin EMC2003-02BC EMC Front-End Validation Process for a narrative description of the messages. Page Numeric Numbering begins with page 1 and increments by 1 for each page within the ISA through IEA. A new ISA through IEA restarts with page 1. Pat Cntl # 20 Positions This is the patient control number that was submitted in the 837, Loop 2300, CLM01. The first 20 positions of the CLM01 element will be printed on the receipt report. Provider Provider Name X positions This is the provider number found in Loop 2010AA REF02, when REF01 = 1A. The provider name is from an internal Empire control file. Receipt Date MM/DD/YY This is the date the transmission was received by the EMC front-end system. Report Heading Different for Production and New Biller Test. The report heading is made up of three or four lines. All reports have the following 3 heading lines: Line 1 Empire Line 2 Electronic Media Claims Line 3 Line of Business Receipt Report The Line of Business is determined by the value in ISA07 and ISA08 values. Blue Cross ISA07 = ZZ ISA08 = 00303 Unknown ISA07 or ISA08 is not a recognized value New Biller Test has an additional 4 th heading line: Line 4 New Biller Test This is determined by the value in ISA15. The value would equal T for a new biller test. Report Number EMCD6102-# This is the EMC front-end system report number. Format: # indicates Production or New Biller transmission 01 Production 11 New Biller Run Date MM/DD/YY This is the date and time when the EMC Receipt Report is run by the EMC front-end Blue Cross Receipt Report 17
Data Dictionary Field Name Values / Format Description Run Time HH:MM:SS system. Segment Count 1-10 This is the value that was submitted in the 837, SE01. (ST/SE) Numeric Segment/Element/ Qualifier Statement Date 13 Positions Defined in the 837 Implementation Guide. D8 Format CCYYMMDD This identifies the segment or element in error. For specifics segments and elements, a qualifier will also be displayed. This will be the date submitted in the 837, Loop 2300, DTP01 equal to 434. The format of the date displayed on the report is based on the qualifier in DTP02. Submitter ID Submitter Name, Contact Name, Street Address, City, State and Zip Code Transaction Set RD8 Format CCYYMMDD- CCYYMMDD This is the value submitted in the 837, ISA06. In the Heading Section, this field is not labeled and appears to the left of Page. The EMC front-end system populates a one-position field after the submitter ID on the first line of the report with the value for the line of business. Values: C Blue Cross U Unknown Unknown will be present when the Line of Business cannot be determined. These fields are based on the submitter ID in the 837, ISA06. These fields are populated from internal Empire control files and identifies the submitter of the 837. This is the value submitted in the 837, ST02. Blue Cross Receipt Report 18
Data Dictionary Field Name Values / Format Description Control Number (ST02) If the 997 is rejected, the message ****997 Rejected**** is displayed next to the Transaction Set Control Number. Transaction Status Passed Failed Partial Passed There are no errors received at any level within the ST through SE. Partial There are lower level errors within the ST through SE that allow some of the claims to be accepted and some to reject. The accepted claims continue processing. The rejected claims need to be corrected and resubmitted. Failed There are errors within the ST through SE that cause the entire ST through SE to reject. All errors must be corrected and the entire ST through SE must be resubmitted. Transmission Mode Transmission Status E-LINK FTP NJE Connect Direct Accept Partial Rejected This is the transmission mode used to transmit the file. Accept There are no errors received at any level within the ISA through IEA. Partial There are errors with some portion of the data within the ISA through IEA. Examples of partial transmissions are: a transmission containing one GS with errors and one error free GS; a transmission containing 3 error free ST/SE s and 1 ST/SE with errors. Rejected Blue Cross Receipt Report 19
Data Dictionary Field Name Values / Format Description The type of errors or the location of errors causes the entire ISA through IEA to reject. Examples of rejected transmissions are: a transmission containing only one GS and that GS has errors; a transmission containing two ST/SE s and both have errors. Version (GS08) 997 Standard Level Edits Performed - Retrieve 997 This is the value submitted in the 837, GS08. A 997 is created for each GS through GE processed through the translator (accepted and rejected) and reports on each ST through SE within the GS through GE. Not Performed Performed-Retrieve 997 The transmission passes all interchange control header edits and a 997 is generated. The Transmission Summary section of the EMC Receipt Report is populated. For those ST through SE s that pass 997 standard level edits, continue to GS edits. For those ST through SE s that fail 997, the message ****997 Rejected**** is generated on the Transaction ST/SE Summary section of the EMC Receipt Report. The ST through SE stops processing. The literal Not Performed is generated for GS IG Level Edits. Not Performed The transmission did not pass interchange control header edits and a 997 is not generated. See Interchange Control Header Edits for additional information. Blue Cross Receipt Report 20
EMC RECEIPT REPORT EXAMPLES Included are specific EMC Receipt Report examples of pass / fail conditions for all levels EMC front-end validation. Example 1 Example 2 Example 3 Example 4 Example 5 Example 6 Example 7 Example 8 Example 9 Level 1 Interchange Control Header (ISA) Edits PASSED Level 2 997 Standard Level Edits PERFORMED-RETRIEVE 997 Level 1 Interchange Control Header (ISA) Edits FAILED Level 2 997 Standard Level Edits NOT PERFORMED Level 2 Functional Group 997 REJECTED Level 2 Transaction (ST / SE) 997 REJECTED Level 3 GS IG Level Edits FAILED Level 4 Implementation Guide (IG) Edits Transaction Level error Level 4 Implementation Guide (IG) Edits Critical IG error Level 4 Implementation Guide (IG) Edits Provider Level error Level 4 Implementation Guide (IG) Edits Subscriber Level error Example 10 Level 4 Implementation Guide (IG) Edits Patient Level error Example 11 Level 4 Implementation Guide (IG) Edits Claim Level error Example 12 Level 5 Empire Business Edits Critical error Example 13 Level 5 Empire Business Edits Provider Authorization error Blue Cross Receipt Report 21
Example 14 Level 5 Empire Business Edits Claim level business error Example 15 Both Level 4 IG Edits & Level 5 Empire Business Edits Example 16 New Biller heading Example 17 No Broadcast Message Example 18 TA1 Message Each example has boxed text explaining the example. Grey shading identifies the specific area of the report highlighted in the example. Blue Cross Receipt Report 22
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 11:07:11 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300033C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 383900007 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY GS IG LEVEL EDITS: PASSED Example 1 Level 1 Interchange Control Header (ISA) Edits PASSED Level 2 997 Standard Level Edits PERFORMED-RETRIEVE 997 This Receipt Report shows a transmission that passed the Interchange Control Header Edits (ISA). When the transmission passes the ISA edits, a 997 is created for each GS through GE. This is indicated by 997 Standards Level Edits: Performed Retrieve 997. Blue Cross Receipt Report 23
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/15/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/15/03 RUN TIME: 11:23:43 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313500023S VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * TRANSMISSION SUMMARY INTERCHANGE CONTROL HEADER EDITS (ISA): FAILED ISA13IEA02 ISA & IEA CONTROL NUMBERS MUST BE PRESENT & MUST MATCH 997 STANDARD LEVEL EDITS: NOT PERFORMED Example 2 Level 1 Interchange Control Header (ISA) Edits FAILED Level 2 997 Standard Level Edits NOT PERFORMED This Receipt Report shows a transmission that failed the Interchange Control Header Edits (ISA). The ISA error begins with ISA and is reported in the Transmission Summary section. When the transmission fails the ISA edits, 997 Standard Level editing is not performed. This is indicated by 997 Standards Level Edits: Not Performed. A 997 is not created. Blue Cross Receipt Report 24
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 09:29:39 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300025C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): GROUP CONTROL NUMBER (GS06): 383900007 ****997 REJECTED**** GS IG LEVEL EDITS: NOT PERFORMED Example 3 Level 2 Functional Group 997 Rejected This Receipt Report shows a functional group that failed the 997 Standard Edits. This is indicated by the message ****997 Rejected**** next to the Group Control Number (GS06). The error information is available on the 997 transaction; it is not displayed on this report. When the functional group fails the 997 Standard Edits, editing stops for this functional group. No Transaction Summary or Provider Summary sections are printed for this functional group. Blue Cross Receipt Report 25
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 09:21:09 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300024C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): GROUP CONTROL NUMBER (GS06): 383900007 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY GS IG LEVEL EDITS: NOT PERFORMED Example 4 Level 2 Transaction (ST/SE) 997 Rejected This Receipt Report shows a transaction (ST through SE) that failed the 997 Standard Edits. This is indicated by the message ****997 Rejected**** next to the Transaction Set Control Number (ST02) on the next page. The error information is available on the 997 transaction; it is not displayed on this report. Because this transmission has only 1 transaction (ST through SE), editing stopped and the GS IG Level Edits were not performed. If a transmission has at least 1 transaction (ST through SE) that passes the 997 Standard Edits, the GS IG Level Edits will be performed. Blue Cross Receipt Report 26
EMCD6102-01 EMPIRE 010101010 C PAGE: 2 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 09:21:09 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300024C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 383900007 TRANSACTION SET CONTROL NUMBER (ST02): 0061 ****997 REJECTED**** EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 31330016C TRANSACTION (ST/SE) DETAIL MESSAGE005 END OF REPORT FOR TRANSACTION SET CONTROL NUMBER 0061 Example 4 continued Level 2 Transaction (ST/SE) 997 Rejected This transaction (ST through SE) failed the 997 Standard Edits. This is indicated by the message ****997 Rejected**** next to the Transaction Set Control Number (ST02). The error information is available on the 997 transaction; it is not displayed on this report. When the transaction (ST through SE) fails the 997 Standard Edits, editing stops for this transaction. No Provider Summary sections are printed for this transaction group. Editing continues with the next transaction in the functional group. Blue Cross Receipt Report 27
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/09/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/09/03 RUN TIME: 15:35:36 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0312900023C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): XX803 GROUP CONTROL NUMBER (GS06): 383900007 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY GS IG LEVEL EDITS: FAILED ERROR CODE GS03000001 GS03000002 ERROR MESSAGE APPLICATION RECEIVER'S CODE MUST = '00303' OR '00303' APPLICATION RECEIVER'S CODE MUST ='00303' WHEN ISA08 ='00303' Example 5 Level 3 GS IG Level Edits FAILED This Receipt Report shows a transmission with a functional group that fails the GS IG level edits. The error information is displayed. No additional editing is done on this functional group. A transaction summary page is printed for each transaction within this functional group. See the following page. Editing continues with the next functional group in the transmission. Blue Cross Receipt Report 28
EMCD6102-01 EMPIRE 010101010 C PAGE: 2 RUN DATE: 05/09/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/09/03 RUN TIME: 15:35:36 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0312900023C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 383900007 TRANSACTION SET CONTROL NUMBER (ST02): 0061 CLAIMS EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 31290017C CLAIMS CLAIMS PASSED TO TRANSACTION STATUS: FAILED RECEIVED REJECTED ADJUDICATION SEGMENT COUNT (ST/SE): 0 0 0 0 MESSAGE005 END OF REPORT FOR TRANSACTION SET CONTROL NUMBER 0061 Example 5 Continued Level 3 GS IG Level Edits FAILED This is the transaction summary page. Because the functional group failed the GS IG level editing, no editing is done for the transaction. The segment count and claims counts are zero. A transaction summary page is printed for each transaction within this functional group. Editing will continue with the next functional group in this transmission. Blue Cross Receipt Report 29
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 11:07:11 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300033C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 383900007 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY GS IG LEVEL EDITS: PASSED Example 6 Level 4 Implementation Guide (IG) Edits Transaction Level error This Receipt Report shows a transaction with transaction level IG errors. Because the transmission passed ISA and 997 edits, and the functional group passed GS IG and 997 edits, there are no errors reported on this page. Error detail is found on the following page in the Transaction Detail section. Blue Cross Receipt Report 30
EMCD6102-01 EMPIRE 010101010 C PAGE: 2 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 11:07:11 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300033C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 383900007 TRANSACTION SET CONTROL NUMBER (ST02): 0061 CLAIMS EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 31330025C CLAIMS CLAIMS PASSED TO TRANSACTION STATUS: FAILED RECEIVED REJECTED ADJUDICATION SEGMENT COUNT (ST/SE): 62 5 5 0 ---------- ERROR KEY ---------- ERROR CODE ERROR MESSAGE AK3043 REQUIRED SEGMENT MISSING IG0056 NM101 ERROR, LOOP NOT RECOGNIZED, A PRIOR LOOP ID ASSIGNED TRANSACTION (ST/SE) DETAIL SEGMENT/ ERROR ERROR ELEMENT/ LEVEL CODE LOOP ID QUALIFIER INPUT DATA TRANSACTION AK3043 1000A NM1 IG0056 1000A NM101 /01 01 Example 6 continued Level 4 Implementation Guide (IG) Edits Transaction Level Error The error key lists all errors reported for the transaction. Implementation Guide (IG) edits begin with AK, IG, or IGE. Because the IG error is a transaction level error, it is reported in the Transaction Detail section. Blue Cross Receipt Report 31
EMCD6102-01 EMPIRE 010101010 C PAGE: 3 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 11:07:11 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300033C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT GROUP CONTROL NUMBER (GS06): 383900007 TRANSACTION SET CONTROL NUMBER (ST02): 0061 EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 31330025C PROVIDER (HL03=20) SUMMARY PROVIDER: ABCD123456789 MEDICAL PROVIDER INC CLAIMS CLAIMS CLAIMS PASSED TO RECEIVED REJECTED ADJUDICATION 5 5 0 MESSAGE002 TRANSACTION LEVEL ERROR: ALL CLAIMS FOR THIS PROVIDER REJECTED MESSAGE005 END OF REPORT FOR TRANSACTION SET CONTROL NUMBER 0061 Example 6 continued Level 4 Implementation Guide (IG) Edits Transaction Level Error Because there is a transaction level error, all claims for the transaction are rejected. A message is printed on every Provider Summary section within the transaction. The individual claims are not listed. If there were any IG errors for any provider, subscriber, patient or claim within the transaction, those IG errors would be reported. Blue Cross Receipt Report 32
EMCD6102-01 EMPIRE 010101010 C PAGE: 1 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 10:40:05 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300027C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT MEDICAL BILLING SERVICE 1234 NORTH STREET ANYTOWN NY 12345 * THIS BOX WILL CONTAIN 240 CHARACTERS FOR A BROADCAST MESSAGE IF NEEDED. * * IF NO MESSAGE IS NEEDED, THE BOX WILL NOT BE DISPLAYED. * * * INTERCHANGE CONTROL HEADER EDITS (ISA): PASSED 997 STANDARD LEVEL EDITS: PERFORMED- RETRIEVE 997 SUBMITTER ID (ISA06): 010101010 APPLICATION RECEIVER CODE (GS03): 00303 GROUP CONTROL NUMBER (GS06): 383900007 TRANSMISSION SUMMARY FUNCTIONAL GROUP (GS/GE) SUMMARY GS IG LEVEL EDITS: PASSED Example 7 Level 4 Implementation Guide (IG) Edits Critical error This Receipt Report shows a transaction with critical IG errors. Because the transmission passed ISA and 997 edits, and the functional group passed GS IG and 997 edits, there are no errors reported on this page. Error detail is found on the following page in the Transaction Detail section. Blue Cross Receipt Report 33
EMCD6102-01 EMPIRE 010101010 C PAGE: 2 RUN DATE: 05/13/03 ELECTRONIC MEDIA CLAIMS CYCLE DATE: 05/13/03 RUN TIME: 10:40:05 BLUE CROSS RECEIPT REPORT RECEIPT DATE: 02/14/03 EMPIRE ENTRY CONTROL NUMBER (ECN): 0313300027C VERSION (GS08): 004010X096A1 INTERCHANGE CONTROL NUMBER (ISA13): 383900007 TRANSMISSION MODE: E-LINK SUBMITTER ID (ISA06): 010101010 TRANSMISSION STATUS: REJECT TRANSACTION (ST/SE) SUMMARY GROUP CONTROL NUMBER (GS06): 383900007 TRANSACTION SET CONTROL NUMBER (ST02): 0061 CLAIMS EMPIRE SUBMISSION CONTROL NUMBER (ST/SE): 31330018C CLAIMS CLAIMS PASSED TO TRANSACTION STATUS: FAILED RECEIVED REJECTED ADJUDICATION SEGMENT COUNT (ST/SE): 62 0 0 0 ---------- ERROR KEY ---------- ERROR CODE ERROR MESSAGE IG0000 CRITICAL ERROR:HL03 MISSING/INV:FURTHER EDITING NOT PERFORMED IG0059 CRITICAL ERROR, 1ST HL03 NOT = 20 OR 2ND HL03 NOT = 22 TRANSACTION (ST/SE) DETAIL SEGMENT/ ERROR ERROR ELEMENT/ LEVEL CODE LOOP ID QUALIFIER INPUT DATA TRANSACTION IG0000 HL03 /2 25 IG0059 HL03 /2 25 MESSAGE005 END OF REPORT FOR TRANSACTION SET CONTROL NUMBER 0061 Example 7 Level 4 Implementation Guide (IG) Edits Critical error The error key lists all errors reported for the transaction. IG edits begin with AK, IG, and IGE. A critical IG edit is defined as an error that may effect the structure of the entire transaction. When a critical IG edit is reported, editing stops. The transaction (ST through SE) is not checked for any other IG errors. Because of structure of the transaction is effected, it is not possible to accurately report claim counts. When a critical IG error is reported, Claims Received, Claims Rejected and Claims Passed to Adjudication are always reported as zero. Blue Cross Receipt Report 34