ANSI Troubleshooting

Presented By:

Deidre Fryfogle- Support Representative

Andrea Frost- Product Manager

ANSI Agenda

What is ANSI?

How is ANSI structured?

What are the most common ANSI data fields I should know?

What is the ANSI Implementation guide and how can I read it?

How do I troubleshoot ANSI-related rejections within ediInsight?

What are some external ANSI tools available to me and my providers?

What is ANSI?

American National Standards Institute is a private, non-profit organization that approves and sets standards in many industries, including healthcare.

In our terms, ANSI format used to exchange insurance claim data between trading partners. Examples are 837 claim file, 997 response file. All ANSI file types have numeric names.

Your practice management system may be capable of creating ANSI claim files. In any case, Practice Insight reads ANSI and various non-ANSI claim files and formats them into the ANSI-compliant format.

For more information on the American National Standards Institute visit their website at www.ansi.org

Purpose of ANSI

The purpose of ANSI is to create a standard file format that can be used throughout the healthcare industry. These formats are intended to comply with the standards set by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Listed below are the names of the most common ANSI files used in healthcare:

ANSI Formats (837) Health Care Claim (835) Health Care Claim Payment/Remittance (270) Health Insurance Eligibility Request (271) Health Insurance Eligibility Response (276) Health Care Claim Status (277) Health Care Service (Referral/Auth) (997) Functional Acknowledgement

ANSI Formats and ediInsight

(837) Health Care Claim- This is the actual claim file we send out to the receiver. You can find it by clicking once on the claim and hitting B (for batch) on your keyboard, to view the outbound claim file.

(835) Health Care Claim Payment/Remittance- This is the Electronic EOB that comes back from the payer detailing a claim payment or denial. You can find this by going into the customer’s transfer files screen, or by clicking on the ERA status line on the claim and hitting E for EOB view.

(270) Health Insurance Eligibility Request- This is the outbound ANSI eligibility request that we send to the receiver. You can view this by going into the Eligibility application, right-clicking on a eligibility transaction, and selecting View ANSI 270/271 data.

(271) Health Insurance Eligibility Response- This is the payer/receiver response to the 270 we send out. You can view this by going into the Eligibility application, right-clicking on a eligibility transaction, and selecting View ANSI 270/271 data.

(276) Health Care Claim Status- This is the Real Time request that we send to a payer/receiver. You can check real time claim status for any claim whose payer is in red print.

(277) Health Care Service (Referral/Auth)- This is the response to the 276 Real-time claim status request we send out. You can view this by clicking on the status-line response that comes back on the claim.

(997) Functional Acknowledgement- This is the response by the receiver that they have received our ANSI 837 file, and that the file passed the basic electronic validation tests. This does not mean that the file has been received by the payer (merely the receiver), or that the file is found to be valid in content. You can find this in the customer’s transfer files screen or on the status-line response that comes back on the claim.

Overall ANSI File Structure

Loops

Loops are the largest structure within an ANSI file. They are comprised of groups of semantically-related segments.

For example Loop 2010AA (the Billing Provider Loop) contains the NM1, N3, N4, and REF segment. The NM1 segment gives the name of the billing provider, N3 and N4 give the location, and the REF segment contains the group Tax ID. An example of a 2010AA billing provider loop is included below:

NM1*85*2*Happy Valley Medical Clinic****XX*1234567890N3*52 E. Main StreetN4*MESA*AZ*85206REF*EI*123456789

**Tips and Tricks**

Different segments will be included depending upon the information being reported in the

loop.

Loops cont…

For a claim to be accepted, there are required loops that must be on the claim. There are also several common loops that are not defined as required but are still usually present on a claim. Below are some examples of common/required loops for a Professional claim.

. Common/Required Loops- Professional

2010AA: Billing Provider (required)

2010AB: Pay-To Provider (situational)

2010BA: Subscriber Name (required)

2010BB: Payer Name (required)

2010CA: Patient Name (required)

2300: Claim Data (required)

2310A: Referring Provider (situational)

2310B: Rendering provider (situational)

2310D: Claim Level Facility (situational)

2400: Service/Transaction Lines (required)

Segments

Segments are the second largest structure within the ANSI file. Each segment is comprised of elements of related information. The Segment Terminator is used to indicate the end of a segment. The Segment Terminator is indicated by a different special character (in this case, a tilde ~). You can tell which special character is required by looking at the ISA segment of an ANSI file. (as shown in more detail later.)

Segments cont..

.

ST: Transaction Set

BHT: Beginning of Hierarchal Transaction

REF: Reference Identification

NM1: Individual or Organizational Name

N2: Additional Name Information

PER: Administrative Communications Contact

HL: Hierarchal Level

PRV: Provider Information

CUR: Currency

N3: Address Information

N4: Geographic Location (City, State, Zip)

SBR: Subscriber Information

PAT: Patient Information

DMG: Demographic Information

CLM: Health Claim (Claim Information)

DTP: Date or Time or Period

PWK: Paperwork

CN1: Contract Information

AMT: Monetary Amount

.

NTE: Note/Special Instructions (Documentation) CR1: Ambulance Certification CR2: Chiropractic Certification CRC: Conditions Indicator (required on Ambulance

claims) HI: Health Care information Codes (Diagnosis

Codes) CR7: Home Health Treatment Certification CAS: Claim Level Adjustments (Needed on secondary

claims) OI: Other Insurance Information LX1: Assigned Number (Reference Line Number in

Transaction Set) SV1: Professional Service (Transaction line level

detail) SV4: Drug Service Detail QTY: Quantity (used for Anesthesia claims) PS1: Purchased Service SVD: Service Line Adjudication

The first part of the segment is called the Segment ID. The Segment ID identifies the type of information contained in the segment. Here are some common Segment IDs for Professional claims. They will vary some from those used in Institutional claims.

Segment IDs- Professional

NM1 SegmentsThe NM1 segment contains an Individual or Organizational Name. The element following the Segment ID is called the Entity Type Code. This code identifies what type of name is being transmitted. Ex: the Referring Provider is indicated by an Entity Type code of DN.

The element following the Entity Type Code is the Entity Type. This field indicates whether or not the entity is a Person (1) or Non-person (2).

NM1*DN*1*HAMILTON*ALEX*X***XX*1234567890

NM1 Entity Type Codes 40: Receiver 41: Submitter 77: Service Location 82: Rendering provider 85: Billing Provider DN: Referring Provider DQ: Supervising Provider FA: Facility IL: Insured or the Subscriber LI: Independent Lab PR: Payer QB: Purchased Service Provider QC: Other Patient Information QD: Responsible Party

REF SegmentsThe REF segment contains identification numbers. In the REF segment, the Segment ID is

followed by the Reference Identification Qualifier. The Reference Identification Qualifier

identifies which type number is contained in the segment. Ex: a REF segment with a

EI qualifier identifies the segment is reporting the tax ID.

REF*EI*123456789

0B: State License Number

1B: Blue Cross/ Blue Shield ID

1C: Medicare ID

1D: Medicaid ID

1G: UPIN

1H: CHAMPUS ID

4N: Special Payment Reference Number

6R: Line Item Control Number

9F: Referral Number

B3: PPO ID

BQ: HMO ID

EW: Mammography Certification Number

EI: Tax ID

F8: Original Reference Number

G1: Prior Authorization Number

G2: Commercial ID

IG: Insurance Policy Number

N5: Provider Plan Network Identification #

LU: Location ID

SY: Social Security Number

X4: CLIA Number

X5: Worker's Comp ID

Y4: Agency Claim Number

REF Segment Reference Identification Qualifiers

DTP SegmentsDTP segments contain Date Time Periods. The element following the Segment ID is the Date Time Qualifier. The Date Time Qualifier identifies what date is contained in the segment. For example 472 indicate that this segment contains the date of service. The following element indicates the format the date is being expressed in and is called the Date Time Period Form Qualifier. The DTP segment is always expressed as CCYYMMDD.

DTP*472*D8*20030219

938: Order Date

454: Initial Treatment Date

330: Referral Date

304: Last Visit or Consultation

431: Onset of Current Symptoms or Illness

453: Acute Manifestation of a Chronic

Condition

438: Onset of Similar Symptoms or Illness

439: Accident Date

484: Last Menstrual Period

455: Last X-Ray

ABC: Estimated Date of Birth

297: Last worked date

435: Admission Date

096: Discharge Date

573: Date Claim Paid

472: Date of Service

Date Time format Qualifiers

**Tips and Tricks**

The D8 qualifier is used to express a single date. There are some situations that will require

a date range. This is expressed using an RD8 qualifier to indicate a range of dates.

Elements

Elements are individual pieces of data that are contained within a segment.

Each element is separated by an Element Delimiter.The Element Delimiter is indicated by a special character (in this case, an asterisk *).

An Element can contain more than one piece of data. These are called sub-elements, and are separated by a special character.

You can easily determine which delimiters the file is using by referencing the end of the ISA segment (the first segment in the ANSI file).

The ISA segment is a fixed length. The first element separator defines the element separator to be used through the entire file.

The segment terminator used after the ISA defines the segment terminator to be used throughout the entire file.

Spaces in the example below are represented by “.” for clarity.

Elements cont…

The first piece of data in the segment is the Segment ID, which defines the type of data to follow.

The next piece of data is the first element in the segment, or, position 01. The next piece of data after the delimiter is position 02, and so on. Any position in the segment that does not contain data is left blank.

NM1*DN*1*HAMILTON*ALEX*X***XX*1234567890

ANSI Implementation Guide

The ANSI implementation guide is the handbook released by HIPAA that tells you how to construct and ANSI claim file.

The ANSI 837 guide is 768 pages long, with another 150+ page addendum.

Each loop is broken out into 4 parts: Implementation, Standard, Diagram, and Element Summary.

Implementation The implementation section of the guide explains how to format the given loop.

Each implementation section contains the loop location, the usage type, and how many of these loops are in a claim.

The notes section gives more clarification on how exactly to format the given loop.

Finally, there is an example of how the first segment should be formatted.

Standard The Standard section of the guide details the basic formatting information regarding

the segment listed.

The first field is the Segment ID that identifies which segment will be described.

The Level field lists the level of the segment.

The Position field tells you the position in the file of the segment identified.

The Loop field tell you the location of the segment.

The Repeat field tells you how many times the loop can repeat.

The Requirement field lets you know whether the segment is required or optional.

The Max Use field tells you how many times you can use the segment per claim.

The Purpose field lets you know the purpose and description of the segment.

Diagram The diagram portion lays out each element that is defined within the segment.

A Bold box indicates a required element.

A strike-through on the text indicates that this element is not used.

The non-bolded boxes, with no strike-through are optional.

Within the boxes in the upper right corner, the segment position is listed.

At the bottom of the boxes, the requirement indicator, data type, and min/max length is listed.

Element Summary The Element Summary section gives a detailed breakout of the element and what it requires.

The top line shows the element requirement status, the segment position, the element name, the requirement indicator, the data type, and the min/max length

Underneath the element name is a brief description of the element, and the Industry and Alias names of the element.

If applicable, the semantic for the element will be listed next, describing the appropriate values and their indicators.

Also optional, is the NSF reference. If there is a related NSF field for this element, it will be listed here.

Finally, the valid values for this element are listed last.

Troubleshooting ANSI Rejections in ediInsight

Now that you have learned to identify the ANSI file structure, troubleshooting ANSI-related rejections within ediInsight becomes easier than you’d think! Have you ever seen a rejection that looks like this?

The text for this rejection reads:

BATCH DELETE 2010AANM1 B P ADTL ID 1396894143 M013- SUBMIT BPRV NOT ON FILE

Troubleshooting cont…

Many payers send back ANSI-laden rejections, like the one seen previously, with no further explanation of the rejection reason! However, if you know ANSI terminology, you can troubleshoot these rejections.

For the example above, the first thing that should pop out at you is the 2010AA. This is a loop that was listed in our common loops slide. It is the billing provider loop. This makes the following text (B P, and BPRV) make a bit more sense.

If you are unsure of the meaning of the loop, or position, you can relate back to your ANSI guide, search for the loop or segment, and use the diagram and element summaries to help you discover the meaning of the rejection.

The number listed in parenthesis next to this loop number is usually the data in error.

Troubleshooting cont… The first tactic I would use is to click once on the big red reject, and hit R

on your keyboard. This will bring up the copy of the payer report that represents the direct source of the rejection message.

Often times, these reports are easier to read, and provide more information. In the example below, you can see how the information correlates with the headings given, and the actual rejection message is much more elaborate.

Troubleshooting cont…

If the payer report does not give you any additional information, or is hard to read, the next thing I would do is take any specific data contained in the reject message and use it to search through the claim that was sent out.

In the example below, a 9 digit number is given to me in parenthesis. I would copy that number and then click once on the claim and hit B for batch. This will bring up the one ANSI claim in the batch that was sent out from ediInsight.

**Tips and Tricks**

EdiInsight breaks up the ANSI claim into readable loops and segments with

headers, as shown in the next slide. An un-edited ANSI claim should just be

one long string of delimited data.

Troubleshooting cont…From here, outbound data will be shown in our viewer with readable loop headers and descriptions. These headers and descriptions do not appear in an outbound ANSI file, but we have added them to make your troubleshooting efforts much easier.

Troubleshooting cont…From here, I would take the data in the error (001447811) and search for it in the outbound batch file…

As you can see, the number refers to the Subscriber’s Identification (or member Id). So without knowing anything about ANSI, you can determine that the payer has a problem with the Subscriber’s Member ID.

External ANSI Help

If you feel a bit overwhelmed, here are a few sources of external references that may help you understand ANSI terminology and requirements a bit better:

http://wpc-edi.com/ This is the link to Washington Publishing Company; the company that publishes the HIPAA based ANSI guides. This is where you can come to purchase any current HIPAA/ EDI Publications and to view the latest ANSI codes.

ANSI Guides- As a convenience for you, Practice Insight has supplied every vendor who has come to a Certified Training with a free copy of the 4010 ANSI Guides and their addendums for the ANSI 837, 835, 270/271, and 276/277 type transactions. Normally you would have to buy them from WPC. These are located on the reseller toolkit you were given when you attended training.

As you may be aware, 5010 is right around the corner. Practice Insight will still accept 4010 type ANSI files after the switch to 5010 is made. We will format all outbound claims in the HIPAA compliant 5010 format after the deadline has passed.

Any Questions?

Thank you for attending our ANSI Troubleshooting webinar.

As always, you can contact support at support@practiceinsight.netwith any questions or assistance you may need.