835 Health Care Claim Payment / Advice

Transcription

1 Companion Document Health Care Claim Payment / Advice This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained in this document are supplemental and should be used in conjunction with the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3 (TR3) as published by the Washington Publishing Company. Section Health Care Claim Payment / Advice: Basic Instructions Section Health Care Claim Payment / Advice: Enveloping Section Health Care Claim Payment / Advice: Charts for Situational Rules Any questions? Contact MCS/JAA representatives dl-mcsit@anthem.com Contact EDI Solutions Desk 1 (800) edi-ca@anthem.com LiveChat Page 1 of 6

2 Section 1 - Basic Instructions 1.1 X12 and HIPAA Compliance Checking, and Business Edits EDI interchanges submitted to Anthem Blue Cross (Anthem) for processing pass through HIPAA Level 1-2 compliance edits. In response to the inbound 835, Anthem will return a 999 to the submitter s trading partner mailbox. 1.2 Basic Format of 835 File Anthem requires that each claim submitted on the 835 has its own transaction set. In other words, all claims and each unique claim must have its own check even if there are multiple claims on the file for the same provider, they must have their own check transaction set. All the claims in 835 contains line level benefit information Anthem systems require claim (2100) and line level details (2110) payment information to be reported on the 835 for ALL (Summary and Detail processed) claims. Whenever possible, we require that all claims be processed and returned back to Anthem in a line level detail. Anthem does not pick up payment/adjudication information from the claim level. 1.3 Uppercase Letters, Special Characters, and Delimiters As specified in the TR3, the basic character set includes uppercase letters, digits, space, and other special characters. All alpha characters must be submitted in UPPERCASE letters only. Suggested delimiters for the transaction are assigned as part of the trading partner set up. EDI Representative will discuss options with trading partners, if applicable. Data Element Separator - Asterisk (*), Sub Element Separator - Colon (:), Segment Terminator - Tilde (~), Repetition Separator - Caret (^) To avoid syntax errors, hyphens, parentheses and spaces are not recommended to be used in values for identifiers. For example, use: Zip Code Medical Record # Claim Payment (CLP) When TPA applies Participating benefits for Non-Participating provider, that will be informed to WGS through 835 File utilizing CLP06 field. The CLP07 data element must be populated with Anthem s Document Control Number (DCN) which represents the claim number. 1.5 Claims Adjustment Reason Codes (CARC)/ Remittance Advice Remark Codes (RARC) The use of HIPAA standards has imposed a limitation on what detailed explanation is reported on the 835 Payment/Advice. It has been determined that proprietary disposition codes may not map one for one to a standard HIPAA claim adjustment reason and/or remittance advice remark code. Anthem system will provide you with a cross reference of EOB Messages utilized in conjunction with the HIPAA EOB Messages that are reported in the CAS segments. Visit under Installation Resources for the most up-to-date Anthem approved 835 CAS code list. Anthem requires to receive the adjustment new payment information on the 835 ONLY. NOTE: Anthem does not require the 835 to contain the take back of the original amounts. Page 2 of 6

3 Section 2 - Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into the following: Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA) 835 Health Care Claim Payment/Advice Envelope Specific to Anthem (TR3, Appendix C) ISA Interchange Control GS Functional Group GE Functional Group IEA Interchange Header Header Trailer Control Trailer ISA01 00 GS01 HP GE01 refer to TR3 IEA01 refer to TR3 ISA02 refer to TR3 GS02 SENDER ID GE02 refer to TR3 IEA02 refer to TR3 ISA03 00 EDI assigned ISA04 refer to TR3 Left-justified followed by ISA05 ZZ no zeroes or spaces ISA06 SENDER ID EDI assigned GS03 BCCA835 Left-justified GS04 refer to TR3 followed by spaces GS05 refer to TR3 GS06 refer to TR3 ISA07 ZZ GS07 X ISA08 BCCA835 GS08 ISA09 refer to TR3 ISA10 refer to TR3 ISA11 ^ (5E) ISA NOTE. Critical Batching and Editing ISA13 refer to TR3 *Transactions must be batched in separate functional group by GS03. ISA14 refer to TR3 *Unique group control number (GS06) MUST NOT be duplicated within 365 ISA15 refer to TR3 days by Trading Partner ID (GS02); files containing duplicate or previously ISA16 refer to TR3 received group control numbers will be rejected. Page 3 of 6

4 Section 3 - Charts for Situational Rules Listed below are loops, segments, and data elements required for proper processing by Anthem per the situational rules in the 835 TR3. TR3 835 Health Care Claim Payment / Advice - Inbound Segment Reference Designator(s) Value Definitions and Notes Specific to MCS P.68 ST Transaction Set Header - Refer to TR3 P.69 BPR Financial BPR04 Payment Method Code ACH CHK NON NON is required when BPR02 = $0.00 BPR16 Represents the claim adjudication date / settlement date. Date P.77 TRN Reassociation Trace Number - Refer to TR3 P.79 CUR CUR02 (Currency Must reflect USD instead of US. Foreign Currency Currency Code Code) P.82 REF REF01 EV EV - Receiver ID Number Receiver Ref ID Qualifier Identification REF02 BCCA835 Represents payments for MCS claims. Ref Identification P.84 REF Version Identification - Refer to TR3 P.85 DTM DTM Production Production Date Date/Time Qualifier DTM02 Date on which adjudication is executed on the claim. Date Loop ID 1000A Payer Identification P.87 N1 Payer Identification - Refer to TR3 P.89 N3 Payer Address - Refer to TR3 P.90 N4 Payer City, State, ZIP Code - Refer to TR3 P.92 REF Additional Payer Identification - Refer to TR3 P.94 PER Payer Business Contact - Refer to TR3 P.97 PER Payer Technical Contact - Refer to TR3 P.100 PER Payer WEB Site - Refer to TR3 Loop ID 1000B Payee Identification P.102 N1 Payee Identification - Refer to TR3 P.104 N3 Payee Address - Refer to TR3 P.105 N4 Payee City, State, ZIP Code - Refer to TR3 P.107 REF Payee Additional Identification - Refer to TR3 P.109 RDM Remittance Delivery Method - Refer to TR3 Loop ID 2000 Header Number P.111 LX Header Number - Refer to TR3 P.112 TS3 Provider Summary - Refer to TR3 P.117 TS2 Provider Supplemental Summary - Refer to TR3 Loop ID 2100 Claim Payment P.123 CLP CLP Preferred Provider Organization (PPO) Claim Payment Claim Filing Claims with these values will be processed with assumption of Indicator Code normal benefits Point of Service (POS) For situations in which a client has assigned PAR benefits to a NON-PAR provider. Anthem will interpret this value as an override of benefits and update our system to the PAR accumulators (when applicable). Page 4 of 6

5 835 Health Care Claim Payment / Advice - Inbound TR3 Segment Reference Designator(s) Value Loop ID 2100 Claim Payment (cont'd) P.123 CLP Claim Payment CLP07 Reference Identification (Payer Claim Control Number) Definitions and Notes Specific to MCS Report the Anthem Document Claim Number (DCN) reported on the 837 REF*D9, REF02. Example: Century/Year Julian Date Camera Reel/SeqNo. Item Code *For reporting adjustments initiated by MCS Client, use 84. P.129 CAS Claim Adjustment - Refer to TR3 Anthem recognizes the CAS segment at the line level (Loop 2110) only. Populating the CAS segment at the claim level (Loop 2100) will result in file failures. P.137 NM1 Patient Name - Refer to TR3 P.140 NM1 Insured Name - Refer to TR3 P.143 NM1 Corrected Patient/Insured Name - Refer to TR3 P.146 NM1 Service Provider Name - Refer to TR3 P.150 NM1 Crossover Carrier Name - Refer to TR3 P.153 NM1 Corrected Priority Payer Name - Refer to TR3 P.156 NM1 Other Subscriber Name - Refer to TR3 P.159 MIA Inpatient Adjudication - Refer to TR3 P.166 MOA Outpatient Adjudication - Refer to TR3 P.169 REF Other Claim Related Identification - Refer to TR3 P.171 REF Rendering Provider Identification - Refer to TR3 P.173 DTM Statement From or To Date - Refer to TR3 P.175 DTM Coverage DTM01 Date/Time Qualifier Expiration Expiration Date DTM02 Date Must be provided by the client/submitter of the 835 when denying a claim due to expiration of coverage. P.177 DTM Claim Received Date - Refer to TR3 P.179 PER Claim Contact - Refer to TR3 P.182 AMT Claim Supplemental - Refer to TR3 P.184 QTY Claim Supplemental Quantity - Refer to TR3 Page 5 of 6

6 835 Health Care Claim Payment / Advice - Inbound TR3 Segment Reference Designator(s) Loop ID 2110 Service Payment P.186 SVC SVC03 Service Payment Monetary Amount SVC05 Quantity P.194 DTM Service Date - Refer to TR3 P.196 CAS CAS01 Service Adjustment Claim Adjustment Group Code CAS02 Claim Adjustment Reason Code CAS03 Monetary Amount CAS04 Quantity Value (Line Item Prov Payment Amount) (Units of Service Paid Count) P.204 REF Service Identification - Refer to TR3 P.206 REF Line Item Control Number - Refer to TR3 P.207 REF Rendering Provider - Refer to TR3 P.209 REF HealthCare Policy Identification - Refer to TR3 P.211 AMT Service Supplemental Amount - Refer to TR3 P.213 QTY Service Supplemental Quantity - Refer to TR3 P.215 LQ Health Care Remark Codes - Refer to TR3 P.217 PLB Provider Adjustment - Refer to TR3 P.228 SE Transaction Set Trailer - Refer to TR3 Definitions and Notes Specific to MCS Must equal SVC02 minus all monetary amounts in the subsequent CAS segments of this loop. A value of 1 or higher needs to be provided only when the claim must update an occurrence/visit. Access the most up-to-date Anthem approved 835 CAS code list by visiting under "Installation Resources." Provide the amount adjusted from the billed/allowed amount in accordance to your system s adjudication determination. A value of 1 or higher needs to be provided only when the claim must update an occurrence/visit towards accumulator. In all other situations a "0" or '' BLANK should be provided. Page 6 of 6