Read 837P%20LONG%20TERM%20CARE%20COMPANION%20GUIDE_5010.pdf text version

837P Long Term Care Companion Guide

ANSI ASC X12N 837P Health Care Claim Professional Long Term Care COMPANION GUIDE

July 1, 2011

Texas Medicaid & Healthcare Partnership

Page 1 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Table of Contents

Section 1: Introduction ......................................................................................................... 3 1.1 Purpose......................................................................................................................... 3 1.2 Contact Information..................................................................................................... 3 1.3 Security and Privacy Statement ................................................................................ 4 1.4 Important Dates ........................................................................................................... 4 1.5 Disclaimer..................................................................................................................... 4 Section 2: 837P Healthcare Claim--Professional ............................................................ 5 Appendix A 837P Example Transaction................................................................................. 8 Appendix B: Summary of Version Changes............................................................................ 9

Texas Medicaid & Healthcare Partnership

Page 2 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Section 1: Introduction

1.1 Purpose

The purpose of this document is to assist the provider with TMHP-particular data sets for information specified in the National Electronic Data Interchange Transaction Set Implementation Guide for the file type. In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the federal government has set standards to simplify Electronic Data Interchange (EDI). To comply with the standard, TMHP has updated the data sets for EDI files to be in accordance with HIPAA and is utilizing the ASC X 12 nomenclatures. The TR3 dated October 2007 was used to create this companion guide for the 837P file format. This companion guide is intended for trading partner use in conjunction with the ANSI ASC X12N National Implementation Guide. The ANSI ASC X12N Implementation Guides can be accessed at www.wpc-edi.com/Insurance_40.asp. The TMHP Companion Guide is designed to provide all entities that submit transactions regarding healthcare claims the specified data sets that TMHP requires per HIPAA compliance for the 837P file format. Not all HIPAA compliant data sets are used by TMHP to process and respond for a request for information. The TMHP EDI Connectivity Guide that contains specific instructions regarding connectivity options can be found on the EDI page of the TMHP website at www.tmhp.com.

1.2

Contact Information

TMHP EDI Helpdesk

The EDI Help Desk provides technical assistance only by troubleshooting TMHP EDI issues. Contact your system administrator for assistance with modem, hardware, or telephone line issues. To reach the TMHP EDI Help Desk, select one of the following methods: · · · Fax 1-512-514-4230 or 1-512-514-4228 For Medicaid, CSHCN and Family Planning electronic filing issues, call 1-888-863-3638 (or call 1-512-514-4150) For Long Term Care issues, call 1-800-626-4117 (Select option 3) (or call 1-512-3354729)

The TMHP EDI Help Desk is available Monday through Friday, 7 a.m. to 7 p.m. CST.

Texas Medicaid & Healthcare Partnership

Page 3 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

1.3

Security and Privacy Statement

Covered entities were required to implement HIPAA Privacy Regulations no later than April 14, 2003. A covered entity is defined as a health plan, a health care clearinghouse, or a health care provider who transmits any health information in electronic form in connection with a HIPAA transaction. Providers that conduct certain electronic transmissions are responsible for ensuring these privacy regulations are implemented in their business practices. HHSC is a HIPAA Covered Entity. Accordingly, TMHP is operating as a HIPAA Business Associate of HHSC as defined by the federally mandated rules of HIPAA. A business associate is defined as a person or organization that performs a function or activity on behalf of a covered entity, but is not part of the covered entity's workforce. The privacy regulation has three major purposes:

1. To protect and enhance the rights of consumers by providing them access to their health

information and controlling the appropriate use of that information; 2. To improve the quality of health care in the United States by restoring trust in the health care system among consumers, health care professionals and the many organizations and individuals committed to the delivery of health care; and 3. To improve the efficiency and effectiveness of health care delivery by creating a national framework for health privacy and protection. In accordance with HIPAA privacy regulations, the state of Texas provided a Notice of Privacy Practices to all Texas Medicaid households. As one of the steps in this process, the state of Texas mailed an "Explanation of Medicaid Privacy Rights and a Privacy Notice" to each Medicaid household in March 2003.

1.4

Important Dates

07/01/2011 ­ 12/31/2011 01/01/2012

5010 Testing and Migration Date: 5010 Cutover:

1.5

Disclaimer

TMHP will accept up to 5000 transactions per batch. If a file is submitted with more than 5000 transactions the entire file will be rejected and not processed by TMHP.

Texas Medicaid & Healthcare Partnership

Page 4 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Section 2: 837P Healthcare Claim--Professional

This section is used to describe the required data sets for Texas Medicaid claim processing by TMHP. The 837P format is used for submission of Electronic Claims for healthcare professionals. This is the file that is sent to TMHP for processing. As an assumption for these file formats, if the Subscriber is the same individual as the Patient then the Patient Loop is not to be populated per HIPAA compliance. Note: X12 files with more than one GS-GE Functional Group will fail to process in the TMHP Claims Management System (CMS) system.

837P Transaction

Loop ID Element ID Data Value Description

Control Segments Interchange Control Header ISA05 ISA06 ISA07 ZZ To Be Assigned ZZ Production = 617591011CMSP Testing = 617591011CMST Mutually Defined TMHP will assign submitter a test and production Submitter ID. Mutually Defined

ISA08

This is the TMHP ID used by CMS for recognition. TMHP requests that all submitters send a | (pipe ­ not alpha) in the ISA11 field as the Repetition Separator. This is a required field in the X12, and also must be different than the data element separator, component element separator, and the segment terminator but TMHP does not support the processing of repeated occurrences of a simple data element or a composite data structure. TMHP will process all 837 transactions as original. TMHP sends any inbound BHT03 value back on the 277CA Claim Response File. The BHT03 is the number assigned by the submitter (submitter's batch id or batch control number) used to identify the transaction within their system. The TMHP Batch id will be listed in bytes 1-8 of BHT03 in the 277CA. The value sent in the 837 BHT03, will be returned in bytes 9 through 30 of the BHT03 value in the 277CA. TMHP will process all 837 transactions as charges.

ISA11

| (pipe ­ not alpha character)

Beginning of Hierarchical Transaction BHT02 00

BHT03

BHT06 Header Submitter Name 1000A PER 03

CH

TE

TE is the code that will note submitter's telephone number is listed in PER04.

Texas Medicaid & Healthcare Partnership

Page 5 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Loop ID

1000A Receiver Name 1000B 1000B

Element ID

PER 04

Data Value

Description

This is the actual telephone number of the submitter. Area Code and Phone Number should be listed in this segment.

NM103 NM109

TMHP 617591011CMSP

TMHP is the name of the payer and the entity that is receiving this transaction. This is TMHP's long term care submitter identification. The value of REF01 must contain EI (EIN), or SY (SSN), based what is sent in REF02. REF02 must contain the EIN or SSN (9 numeric). TE is the code that will note billing provider's telephone number is listed in PER04. This is the actual telephone number of the billing provider. Area Code and Phone Number should be listed in this segment.

Billing Provider Name 2010AA 2010AA 2010AA 2010AA REF01 REF02 PER03 PER04 EI or SY 9 numeric TE

Detail, Subscriber Hierarchical Level Subscriber Name 2010BA 2010BA NM108 NM109 MI TMHP requests that the submitter enter MI for the Client ID for proper adjudication of the file. The Client ID will continue to be a maximum of 9 characters in length of the 80 that are allotted by HIPAA. The name of the organization or the last name of the individual that expects to receive information or is receiving information. This is the Payer Name It is recommended by TMHP that the submitter use PI in this segment when submitting an 837P to TMHP for a request. This is the Payor ID used to process this type of request. The value of REF01 must contain G2 when the API is sent in REF02. If an API is sent, REF02 must contain the API.

Payer Name 2010BB NM103 TDHS/TDMHMR

2010BB 2010BB 2010BB

NM108 NM109 REF01

PI 324/655 G2

2010BB REF02 10 alphanumeric Detail, Patient Hierarchical Level Claim Information Medical Record Number 2300 REF02 Referral Number 2300 REF01 9F EA

REF01 is EA then the Trace Sequence Number should be submitted in REF02 and the segment can be up to 30 characters in length. REF02 must contain 9F if the Referral Number is present. (Situational)

Texas Medicaid & Healthcare Partnership

Page 6 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Loop ID

Element ID

REF02

Data Value

Description

REF02 must contain a valid referral number and is recommended by TMHP. The referral number is needed to crosswalk to the provider's contract number for claim processing. (Situational)

2300

8 numeric

Healthcare Diagnosis Code 2300 TMHP will only capture the first 4 diagnosis codes (HI01 to HI04) for processing the file. Referring Provider Information (Loop Situational-HIPAA) HI01 AA

Note: If the Referral number is not sent on the claim, loop 2310A is not required by TMHP. NM101 must contain DN if 2300 REF01 and REF02 are 2310A NM101 DN populated with the referral number. 2310A 2310A 2310A 2310A NM102 NM103 NM104 NM108 1 DADS DADS XX NM102 must contain a value of 1 for a person entity type. NM103 must contain the last name of DADS. NM104 must contain the first name of DADS. If the referral number is submitted in loop 2300 (REF01=9F), the NM108 will contain XX for the Department of Aging and Disability Services (DADS) NPI. NM109 must contain"1568578417" if the referral number is sent in loop 2300 (REF01=9F).

2310A

NM109

10 numeric

Rendering Provider Information (Loop Situational ­ HIPAA) 2310B 2310B Service Line 2400 2400 SV103 SV104 UN TMHP is requesting that the data set in this segment be UN for proper adjudication of the file. TMHP can accept a maximum of 99,999.99 for the units counted for claims processing. REF01 REF02 G2 10 alphanumeric The value of REF01 must contain G2 when the API is sent in REF02. If an API is sent, REF02 must contain the API

Rendering Provider Name Rendering Provider Name 2420A 2420A REF01 REF02 G2 10 alphanumeric The value of REF01 must contain G2 when the API is sent in REF02. If an API is sent, REF02 must contain the API.

Texas Medicaid & Healthcare Partnership

Page 7 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Appendix A

837P Example Transaction

The 837P transaction is designed to transmit one or more claims for each billing provider. The hierarchy of the looping structure is billing provider, subscriber, claim level, and claim service line level. Billing providers who sort claims using this hierarchy will use the 837P more efficiently because information that applies to all lower levels in the hierarchy will not have to be repeated within the transaction. TMHP Note: As an assumption for these file formats, if the Subscriber is the same individual as the Patient then the Patient Loop is not to be populated per HIPAA compliance. Information sent in the 2000C loop will be rejected by TMHP. In the following example carriage return line feeds are inserted in place of ~ character for improved readability purposes.

TMHP Example Transaction:

ISA*00* *00* *ZZ*146000650 *ZZ*745169157 *061218*1002*|*00501*111111111*0*P*: GS*HC*146000650*745169157*20101130*1437*9*X*005010X222A1 ST*837*0001*005010X222A1 BHT*0019*00*123456*20101130*1437*CH NM1*41*2*SUBMITTER NAME*****46*999999999 PER*IC*SUBMITTER CONTRACT INFO*TE*5555555555 NM1*40*2*RECEIVER NAME*****46*999999999 HL*1**20*1 NM1*85*2*BILLING PROVIDER NAME*****XX*9999999999 N3*580 ADDRESS N4*CITY*TX*787271234 REF*EI*999999999 HL*2*1*22*0 SBR*P*18*******MC NM1*IL*1*LNAME*FNAME*MNAME***MI*999999999 N3*14903 ADDRESS N4*CITY*TX*78727 DMG*D8*19500922*F NM1*PR*2*PAYER NAME*****PI*3240655 CLM*96406546570045406540*152.3***11:B:1*Y*C*Y*Y REF*9F*12345678 HI*BK:0020 NM1*DN*1*DADS*DADS****XX*1568578417 NM1*82*2*PROVIDER NAME*****XX*1234567893 LX*1 SV1*HC:S9123:TD*152.3*UN*1***1 DTP*472*RD8*20101001-20101001 NM1*82*1*LNAME*FNAME****XX*9999999999 SE*27*0001 GE*1*9 IEA*1*111111111

Texas Medicaid & Healthcare Partnership

Page 8 of 9

Print Date:

7/31/2012

837P Long Term Care Companion Guide

Appendix B:

Summary of Version Changes

The following is a log of changes made since the original version of the document was published. Change Date

Texas Medicaid & Healthcare Partnership

Page 9 of 9

Print Date:

7/31/2012

Information

9 pages

Find more like this

Report File (DMCA)

Our content is added by our users. We aim to remove reported files within 1 working day. Please use this link to notify us:

Report this file as copyright or inappropriate

1324377


You might also be interested in

BETA
PBIv8n9.qxd
A BASIC GUIDE TO NCPDP STANDARDS
Microsoft Word - PEER REVIEW TRAINING.doc
eMedNY Subsystem User Manual