HEALTH CARE CLAIM Companion Guide - vimmis.com Guides/USVI 5010... · Health Care Claim transactions. Refer to the “Health Care Claims (837)” ASC X12N Implementation Guide for

Government of the Virgin Islands of the United States

Date of Publication: 02/06/2013

Version: 1.5

USVI

HEALTH CARE CLAIM

837

Companion Guide


© 2018 DXC Technology Company. All rights reserved. Page 2 of 33

DXC Confidential Information

DISCLAIMER

The DXC Technology Companion Guide for USVI Medicaid is subject to change prior to January 1,

2013 or at the instruction of the Department. Therefore, it is the responsibility of the trading

partner to ensure that the latest version of this guide is used when designing\building NX12 5010

EDI transactions. The trading partner should frequently check for updates to the companion guide.

DXC Technology accepts no liability for any costs that the trading partner may incur that arise from

or are related to changes to the companion guide.




Preface

This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata

adopted under HIPAA clarifies and specifies the data content when exchanging electronically with

DXC Technology. Transmissions based on this companion guide, used in tandem with the v5010

ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This

Companion Guide is intended to convey information that is within the framework of the ASC X12N

Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to

convey information that in any way exceeds the requirements or usages of data expressed in the

Implementation Guides.




EDITOR'S NOTE

This page is blank because major sections of a book should begin on a right hand page.




Table of Contents

INTRODUCTION ................................................................................................................................................................... 7

SCOPE ...................................................................................................................................................................................... 8 OVERVIEW ............................................................................................................................................................................... 8 REFERENCES ............................................................................................................................................................................ 8 ADDITIONAL INFORMATION .................................................................................................................................................... 8

GETTING STARTED ............................................................................................................................................................... 8

WORKING WITH DXC TECHNOLOGY ........................................................................................................................................ 8 TRADING PARTNER REGISTRATION ......................................................................................................................................... 8 CERTIFICATION AND TESTING OVERVIEW ............................................................................................................................... 9 TESTING WITH THE PAYER ....................................................................................................................................................... 9

CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ........................................................................................................ 9

PROCESS FLOWS ...................................................................................................................................................................... 9 TRANSMISSION ADMINISTRATIVE PROCEDURES .................................................................................................................... 9 RE-TRANSMISSION PROCEDURE .............................................................................................................................................. 9 COMMUNICATION PROTOCOL SPECIFICATIONS ................................................................................................................... 10 PASSWORDS .......................................................................................................................................................................... 10

CONTACT INFORMATION ................................................................................................................................................... 10

EDI CUSTOMER SERVICE ........................................................................................................................................................ 10 EDI TECHNICAL ASSISTANCE .................................................................................................................................................. 10 PROVIDER SERVICE NUMBER ................................................................................................................................................. 10 APPLICABLE WEBSITES/E-MAIL .............................................................................................................................................. 10

CONTROL SEGMENTS AND ENVELOPES ............................................................................................................................. 10

VALID DELIMITERS FOR USVI MEDICAID ......................................................................................................................................... 10 ISA-IEA ................................................................................................................................................................................... 11 GS-GE ..................................................................................................................................................................................... 12 ST-SE ...................................................................................................................................................................................... 12

PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ......................................................................................................... 13

ACKNOWLEDGEMENTS AND/OR REPORTS ........................................................................................................................ 13

REPORT INVENTORY .............................................................................................................................................................. 13

TRADING PARTNER AGREEMENTS ..................................................................................................................................... 14

TRADING PARTNERS .............................................................................................................................................................. 14

TRANSACTION SPECIFIC INFORMATION ............................................................................................................................. 14

FIELD DEFINITIONS ................................................................................................................................................................ 14 837 PROFESSIONAL TRANSACTION COMPANION GUIDE ...................................................................................................... 15 837 INSTITUTIONAL TRANSACTION COMPANION GUIDE ...................................................................................................... 18 837 DENTAL TRANSACTION COMPANION GUIDE .................................................................................................................. 24 ATYPICAL PROVIDERS ............................................................................................................................................................ 27 ADDITIONAL PROVIDER INFORMATION ................................................................................................................................ 28

APPENDICES ...................................................................................................................................................................... 29




IMPLEMENTATION CHECKLIST ....................................................................................................................................................... 29 TRANSMISSION EXAMPLES ........................................................................................................................................................... 29

TA1 Interchange Acknowledgement ................................................................................................................................. 29 999 Implementation Acknowledgement for Health Care Insurance ................................................................................. 30 824 Application Advice ...................................................................................................................................................... 30 Business Rejection Report ................................................................................................................................................. 32

FREQUENTLY ASKED QUESTIONS .................................................................................................................................................. 32 CHANGE SUMMARY .................................................................................................................................................................... 32




INTRODUCTION

This guide describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be

detailed with the use of a table. The tables contain a row for each segment that DXC Technology

has something additional, over and above, the information in the IGs. That information can:

Limit the repeat of loops, or segments

Limit the length of a simple data element

Specify a sub-set of the IGs internal code listings

Clarify the use of loops, segments, composite and simple data elements

Any other information tied directly to a loop, segment, composite or simple data element

pertinent to trading electronically with DXC Technology

In addition to the row for each segment, one or more additional rows are used to describe DXC

Technology’s usage for composite and simple data elements and for any other information. Notes

and comments should be placed at the deepest level of detail. For example, a note about a code

value should be placed on a row specifically for that code value, not in a general note about the

segment.

The following table specifies the columns and suggested use of the rows for the detailed

description of the transaction set companion guides.

Page

#

Loop

ID

Reference Name Codes Length Notes/Comments

193 2100C NM1 Subscriber

Name

This type of row always exists to

indicate that a new segment has

begun. It is always shaded at 10

percent and notes or comment about

the segment itself goes in this cell.

195 2100C NM109 Subscriber

Primary

Identifier

15 This type of row exists to limit the

length of the specified data element.

196 2100C REF Subscriber

Additional

Identification

197 2100C REF01 Reference

Identification

Qualifier

18, 49,

6P, HJ,

N6

These are the only codes transmitted

by DXC Technology.

Plan Network

Identification

Number

N6 This type of row exists when a note

for a particular code value is

required. For example, this note may

say that value N6 is the default. Not

populating the first three columns

makes it clear that the code value

belongs to the row immediately

above it.

218 2110C EB Subscriber

Eligibility or

Benefit

Information




Page

#

Loop

ID

Reference Name Codes Length Notes/Comments

231 2110C EB13-1 Product/Service

ID Qualifier

AD This row illustrates how to indicate a

component data element in the

Reference column and how to specify

that only one code value is

applicable.

SCOPE

This companion guide documents the transaction type listed below and further defines situational

and required data elements that are used for processing claims for programs administered by USVI

Medicaid. This document is not the complete EDI transaction format specifications. Refer to the

ASC X12N Implementation Guides or 5010 TR3s for information not supplied in this document,

such as code lists, definitions, and edits.

OVERVIEW

Data elements, segments, and loops not included in this guide are not used for processing claims

by USVI Medicaid, but will still be sent if the information is required for compliance with the ASC

X12N version 5010A2 format.

REFERENCES

The ASC X12N Implementation Guides or 5010 TR3s (Type 3 Technical Report) are standards

developed by the X12 committee and published by the Washington Publishing Company (WPC).

http://store.x12.org/store/healthcare-5010-consolidated-guides

ADDITIONAL INFORMATION

Assumptions regarding the reader

You are interested in reducing error, maximizing efficiency, and saving money.

USVI Medicaid encourages all providers to receive and make use of the standard HIPAA

837 Healthcare Claim.

Advantages / Benefits of EDI

The 837 Healthcare Claim allows for electronic submission of claims data sent to USVI

Medicaid using computer software.

GETTING STARTED

WORKING WITH DXC TECHNOLOGY

Please visit http://www.vimmis.com for information.

For any questions, or to begin testing, please contact the DXC Technology EDI Helpdesk at 1-855-

248-7536 or email us at [email protected].

TRADING PARTNER REGISTRATION

A trading partner is defined as any entity with which DXC Technology exchanges electronic data.

The term electronic data is not limited to HIPAA X12 transactions. USVI Medicaid’s Health PAS

system supports the following categories of trading partner:


http://www.vimmis.com/





Provider

Billing Agency

Clearinghouse

Other

DXC Technology will assign trading partner IDs to support the exchange of X12 EDI transactions

for providers, billing agencies and clearinghouses.

To obtain a trading partner ID please visit our website at: http://www.vimmis.com or contact us at

1-855-248-7536.

CERTIFICATION AND TESTING OVERVIEW

All trading partners must be authorized to submit production EDI transactions. Any trading partner

may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control

Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a

per transaction basis. For example, a trading partner may be certified to submit 837P professional

claims but not certified to submit 837I institutional claim files.

Refer to the USVI Health Pas Web Portal Provider User Guide for more information. The user guide

can be found at https://www.vimmis.com/user%20guides/forms/allitems.aspx.

TESTING WITH THE PAYER

Trading partners must submit three test files of a particular transaction type, with a minimum of

fifteen transactions within each file, and have no failures or rejections to become certified for

production. Review the “EDI Certification Status” page of Health PAS-OnLine under the “Account

Maintenance” menu option to verify when testing for a particular transaction has been completed.

The EDI Certification Status page is found by logging in to your trading partner account on the

Health PAS-OnLine Website (www.vimmis.com).

Detailed instructions for retrieving and interpreting HIPAA validation acknowledgments may be

found in the Business Scenarios and Transmission Examples appendices found at the end of this

companion guide.

CONNECTIVITY WITH THE PAYER/COMMUNICATIONS

PROCESS FLOWS

The 837 Healthcare Claim transaction process flow is not available at this time and will be updated

when mandated by CAQH operating rules.

TRANSMISSION ADMINISTRATIVE PROCEDURES

X12 files can be uploaded via Health PAS-OnLine File Exchange X12 Upload.

837 Healthcare Claim transaction files, Acknowledgments and Responses to transactions submitted

via the Health PAS-OnLine website can be accessed by selecting Claims (837) under the File

Exchange menu.

RE-TRANSMISSION PROCEDURE

ISA13 – Interchange Control Number needs to be unique to each file and Trading Partner ID.



https://www.vimmis.com/User%20Guides/Forms/AllItems.aspx





COMMUNICATION PROTOCOL SPECIFICATIONS

The following communications protocols are available for sending and receiving the ASC X12N 837

Health Care Claim transactions.

Refer to the “Health Care Claims (837)” ASC X12N Implementation Guide for more information on

submitting Batch and Real-time transactions.


PASSWORDS

Trading Partners create their own password at time of registration and are required to update it

every 60 days as per the Health PAS-OnLine requirements. Password must be at least eight (8)

characters consisting of an upper and lower case letter, a special character such as # or * or ^

(except ,) and a number. A password may not start with the first three characters of the User

Name. The web portal account will become locked after five incorrect password attempts. The

user will need to utilize the “Unlock” link to reset the password or contact the EDI Helpdesk.

CONTACT INFORMATION

EDI CUSTOMER SERVICE

Contact DXC EDI Helpdesk at 1-855-248-7536 or email [email protected].

EDI TECHNICAL ASSISTANCE

Contact DXC EDI Helpdesk at 1-855-248-7536 or email [email protected].

PROVIDER SERVICE NUMBER

Contact Provider Services at 1-340-715-6929 or email [email protected]

APPLICABLE WEBSITES/E-MAIL

The email addresses below can be used in contacting USVI Medicaid’s EDI Support, Provider

Services, and the Provider Enrollment department. These groups can provide assistance and

answer questions relating to EDI file submissions, provider enrollment, and services.

Website -- http://www.vimmis.com

EDI Support – [email protected]

Provider Services – [email protected]

Provider Enrollment – [email protected]

CONTROL SEGMENTS AND ENVELOPES

Valid Delimiters for USVI Medicaid

A delimiter is a character used to separate two data elements or component elements or to

terminate a segment. The delimiters are an integral part of the data.

USVI Medicaid does not require the use of specific values for the delimiters used in electronic

transactions. The suggested values are included in the specifications below.








Definition ASCII Decimal Hexadecimal

Segment Separator ~ 126 7E

Element Separator * 42 2A

Compound Element Separator : 58 3A

ISA-IEA

The following ISA/IEA fields are the sender and receiver specific information listed in the 837

transactions. The ISA segment must equal a 105 byte fixed length record, followed by a segment

terminator delimiter equaling a total of 106 bytes. For all other fields, see the transaction specific

information table in section Transaction Specific Information.

ISA06 – Interchange Sender ID will contain the DXC assigned trading partner ID.

ISA08 – Interchange Receiver ID will contain VI_MMIS_4_DXCMS.

ISA13 – Sender generated Interchange Control Number. This number must be unique in each file

submission and will match the number in IEA02.

ISA - INTERCHANGE CONTROL HEADER SEGMENT

Reference Definition Values

ISA01 Authorization Information

Qualifier

00

ISA02 Authorization Information [space fill]

ISA03 Security Information

Qualifier

00

ISA04 Security Information [space fill]

ISA05 Interchange ID Qualifier ZZ

ISA06 Interchange Sender ID Insert with the unique number found on

your USVI Transaction Information Form.

ISA07 Interchange ID Qualifier ZZ

ISA08 Interchange Receiver ID VI_MMIS_4_DXCMS

ISA09 Interchange Date The date format is YYMMDD

ISA10 Interchange Time The time format is HHMM

ISA11 Repetition Separator ^

ISA12 Interchange Control Version

Number

00501

ISA13 Interchange Control

Number

Must be identical to the interchange trailer

IEA02 (defined by sending Trading Partner)

ISA14 Acknowledgment Request 1

ISA15 Usage Indicator T= Test Data

P = Production Data

ISA16 Component Element

Separator

:

IEA - INTERCHANGE CONTROL TRAILER





IEA01 Number of included

Functional Groups

Count of included Functional Groups

IEA02 Interchange Control

Number

Must be identical to the value in ISA13

GS-GE

The following GS/GE fields are the sender and receiver specific information listed in the 837

transactions. For all other fields, see the transaction specific information table in section

Transaction Specific Information.

GS02 – Interchange Sender ID will contain the DXC assigned trading partner ID.

GS03 – Interchange Receiver ID will contain VI_MMIS_4_DXCMS.

GS06 – Sender generated Group Control Number, will match the number in GE02.

GS – FUNCTIONAL GROUP HEADER


GS01 Functional Identifier Code HC = Health Care Claim (837)

GS02 Application Sender’s Code Must be identical to the value in ISA06

GS03 Application Receiver’s Code VI_MMIS_4_DXCMS

GS04 Date The date format is CCYYMMDD

GS05 Time The time format is HHMM

GS06 Group Control Number Assigned and maintained by the sender

GS07 Responsible Agency Code X

GS08 Version/Release/Industry

Identifier Code

Appropriate Version Code for the claim

GE – FUNCTIONAL GROUP TRAILER


GE01 Number of Transaction Sets

Included

Number of Transaction Sets included

GE02 Group Control Number Must be identical to the value in GS06

ST-SE

The following ST/SE fields are the sender and receiver specific information listed in the 837

transactions. For all other fields, see the transaction specific information table in section

Transaction Specific Information.

ST02 – Sender generated Transaction Set Control Number and must match the number in SE02.




ST – TRANSACTION SET HEADER


ST01 Transaction Set Identifier

Code

Code uniquely identifying a Transaction Set

ST02 Transaction Set Control

Number

Must be identical to the value in SE02

ST03 Implementation Guide

Version Name

Must be identical to the value in GS08

SE – TRANSACTION SET TRAILER


SE01 Transaction Segment Count Total number of segments included in a

transaction set including ST and SE.

SE02 Transaction Set Control

Number

Must be identical to the value in ST02

For all other fields, see the transaction specific information table in section Transaction Specific

Information.

PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS

Listed below are the transmission constraints associated with the submission of the 837 Healthcare

claim transaction:

Only one Interchange per transmission

Only one transaction type per interchange

Maximum of 5,000 claims per transmission

Single transmission file size must be less than 5 MB

For DXC Technology specific business rules and limitation in association with the ASC X12N 837

Healthcare Claim transaction, refer to section Transaction Specific Information.

ACKNOWLEDGEMENTS AND/OR REPORTS

The acknowledgements and/or reports listed below are related to the submission of EDI

transactions by a trading partner. These acknowledgements and/or reports are downloaded via the

Heath PAS-OnLine Web portal or through FTP for those providers that submit transactions from an

FTP connection. Additional information about retrieving and interpreting acknowledgements and/or

reports can be found in the Transmission Example Appendix.

REPORT INVENTORY

TA1 – Interchange Acknowledgement. This acknowledgement is sent if requested by

setting ISA14 to ‘1’, or if ISA14 is set to ‘0’ and there is an error that needs to be

reported.

999 – Functional Acknowledgement. This acknowledgement file reports any errors found

while checking compliance against TR3 specifications, or acceptance of an EDI

transaction that meets the TR3 specifications for SNIP levels 1 and 2.

277 Claim Acknowledgement – This transaction is not mandated by HIPAA, but will be




used to report claims that have been accepted for adjudication as well as those that are

not accepted due to compliancy errors when submitted through the 837 transaction.

824 Application Advice Report. This transaction is not mandated by HIPAA, but will be

used to report the results of data content edits of transaction sets. It is designed to

report rejections based on business rules such as; invalid diagnosis codes, invalid

procedure codes, and invalid provider numbers. The 824 Application Advice report does

not replace the 999 or TA1 transactions and will only be generated by Health PAS if

there are errors within the transaction for SNIP level 3 through 7.

BRR – Business Rejection Report. Health PAS also produces a readable version of the

824 called the Business Rejection Report (BRR). This report helps to facilitate the

immediate correction and re-bill of claims rejected during HIPAA validation for SNIP

levels 1 through 7.

TRADING PARTNER AGREEMENTS

TRADING PARTNERS

A trading partner is defined as any entity with which DXC exchanges electronic data. The term

electronic data is not limited to HIPAA X12 transactions. USVI Medicaid’s Health PAS system

supports the following categories of trading partner:

Provider

Billing Agency

Clearinghouse

Health Plan

DXC will assign trading partner IDs to support the exchange of X12 EDI transactions for providers,

billing agencies and clearinghouses, and other health plans.

All trading partners must be authorized to submit production EDI transactions. Any trading partner

may submit test EDI transactions. The Usage Indicator, element 15 of the Interchange Control

Header (ISA) of an X12 file, indicates if a file is test or production. Authorization is granted on a

per transaction basis. For example, a trading partner may be certified to submit 837P professional

claims but not certified to submit 837I institutional claim files.

TRANSACTION SPECIFIC INFORMATION

Listed in the following tables are the specific requirements for submitting and processing an ASC

X12N 837 Healthcare Claim transaction file to DXC Technology. Use these guidelines in

conjunction with the official ASC X12N 837 TR3 document to submit 837 Healthcare Claim

transaction files.

FIELD DEFINITIONS

Label Column Definition

A The name of the loop as documented in the appropriate 837 TR3.

B A loop ID number used to identify a group of segments that are collectively

repeated in a serial fashion up to a specified maximum number of times as

documented in the appropriate 837 TR3.

C The field position number and segment number as specified in the appropriate

837 TR3.




Label Column Definition

D The data element name as indicated in the appropriate 837 TR3.

E The Values and Comments further describing the appropriate 837 TR3 field data

that USVI Medicaid will accept.

837 PROFESSIONAL TRANSACTION COMPANION GUIDE

The 837 Professional Versions used in creating the guide.

Health Care Claim: Professional 005010X222 May 2006

Health Care Claim: Professional 005010X222A1 October 2007

Health Care Claim: Professional 005010X222A2 June 2010

Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Version/Release/Industry

Identifier Code

GS08 Identification

Code

005010X222A1

Beginning of Hierarchical

Transaction

BHT02

Transaction Set

Purpose Code

‘00’ Original

Beginning of Hierarchical BHT06 Transaction Type ‘CH’ Chargeable

Transaction Code

Submitter Name 1000A NM109 Identification

Code

Insert with the unique

number found on

your USVI

Transaction

Information Form.

Submitter Contact

Information

1000A PER03 Communication

Number Qualifier

‘TE’ Telephone

Minimum

requirement, PER 05

–PER08 may also be

sent.

Receiver Name 1000B NM103 Name Last or

Organization

Name

VI_MMIS_4_DXCMS

Receiver Name 1000B NM109 Identification

Code

VI_MMIS_4_DXCMS

Billing Provider Name

2010AA NM108 Identification

Code Qualifier

‘XX’ National Provider

ID. Atypical Providers

refer to Atypical

Section.



Code

Billing Provider




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

National Provider ID.

Usage changed to

situational.

Billing Provider Address 2010AA N403 Postal Code

Billing Provider Zip

Code must be the

full 9 digits

Subscriber Hierarchical

Level

2000B HL04 Hierarchical Child

Code

‘0’ No subordinate

HL Segment in the

Hierarchical

Structure

Subscriber Information 2000B SBR09 Claim Filing

Indicator Code

MC

Subscriber Name 2010BA NM102 Entity Type

Qualifier

‘1’ Person

Subscriber Name 2010BA NM108 Identification Code

Qualifier

‘MI’ Member

Identification

Number

Subscriber Name 2010BA NM109 Identification

Code

USVI Medicaid 10

digit Recipient

Number

Payer Name 2010BB NM103 Name Last or

Organization

Name

VI_MMIS_4_DXCMS

Payer Name 2010BB NM108 Identification Code

Qualifier

‘PI’ Payer

Identification

Payer Name 2010BB NM109 Identification

Code

VI_MMIS_4_DXCMS

Claim Information 2300 CLM01 Claim Submitter’s

Patient Account /

Identifier Number

Patient Control

Number

Claim Information 2300 CLM06 Yes/No Condition

or Response

Code

‘Y’ Yes


or Response

Code

‘Y’ Yes

Health Care Diagnosis

Code

2300 HI01-2 Industry Code

Diagnosis Code

Required on all

claims.

Transportation claims

use 799.0 when

unknown.

Referring Provider Name 2310A NM108 Identification Code

Qualifier

‘XX’ National

Provider ID

Referring Provider Name 2310A NM109 Identification

Code

Referring Provider

National Provider ID




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Rendering Provider

Name

2310B NM108 Identification Code

Qualifier

‘XX’ National

Provider ID

Rendering Provider

Name

2310B NM109 Identification

Code

Rendering Provider


Rendering Provider Name 2310B PRV01 Provider Code ‘PE’ Performing

SBR-Other Subscriber

Information

2320 SBR09 Claim Filing

Indicator Code

Please ensure to

use the correct

indicator code(s)

when billing VI

Medicaid as a

secondary or

tertiary payer.

Do not send ‘MC’ in

this Position/

Segment for

secondary or

tertiary claims.

Valid values are:

‘11’ – Other

NonFederal

Programs

‘12’ – Preferred

Provider

Organization

(PPO)

‘13’ – Point of

Service (POS) ‘14’

– Exclusive

Provider

Organization

(EPO)

‘15’ – Indemnity

Insurance

‘16’ – Health

Maintenance

Organization

(HMO) Medicare

Risk

‘17’ – Dental

Maintenance

Organization

‘AM’ – Automobile

Medical

‘BL’ – Blue Cross/




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Blue Shield

‘CH’ – Champus

‘CI’ – Commercial

Insurance Co

‘DS’ – Disability

‘FI’ – Federal

Employees

Program

‘HM’ – Health

Maintenance

Organization

‘LM’ – Liability

Medical

‘MA’ – Medicare

Part A

‘MB’ – Medicare

Part B

‘OF’ – Other

Federal Program

‘TV’ – Title V

‘VA’ – Veterans

Affairs Plan

‘WC’ – Workers’

Compensation

Health Claim

‘ZZ’ – Mutually

Defined

Line Adjustment 2430 CAS01 Claim Adjustment

Group Code

‘CR’ Correction and

Reversals

‘CO’ ‘OA’ ‘PI’ ‘PR’


Reason Code

For adjustment

reason codes see

http://wpc-edi.com

Line Adjustment 2430 CAS03 Monetary Amount

Adjusted Amount

Line Level

Line Adjustment 2430 CAS04 Quantity/Adjusted

Units – Line Level

837 INSTITUTIONAL TRANSACTION COMPANION GUIDE

The 837 Institutional Versions used in creating the guide.

Health Care Claim: Institutional 005010X223 May 2006

Health Care Claim: Institutional 005010X223A1 October 2007

Health Care Claim: Institutional 005010X223A2 June 2010

http://wpc-edi.com/

http://wpc-edi.com/

http://wpc-edi.com/




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Version/Release/Industry

Identifier Code

GS08 Identification

Code

005010X223A2


Transaction

BHT02

Transaction Set

Purpose Code

‘00’ Original


Transaction

BHT06

Transaction Type

Code

‘CH’ Chargeable

Submitter Name 1000A NM109 Identification

Code

Insert with the unique

number found on

your USVI

Transaction

Information Form.

Submitter Contact

Information

1000A PER03 Communication

Number Qualifier

‘TE’ Telephone

Minimum

requirement, PER 05

–PER08 may also be

sent.

Receiver Name 1000B NM103 Name Last or

Organization

Name

VI_MMIS_4_DXCMS

Receiver Name 1000B NM109 Identification

Code

VI_MMIS_4_DXCMS



Code Qualifier

‘XX’ National Provider

ID. Atypical

Providers refer to

Atypical Section.



Code

Billing Provider

National Provider ID.

Usage changed to

situational.

Billing Provider Address 2010AA N403 Postal Code

Billing Provider Zip

Code must be the

Full 9 digits

Subscriber Hierarchical

Level

2000B HL04 Hierarchical Child

Code

‘0’ No subordinate

HL Segment in the

Hierarchical

Structure

Subscriber Information 2000B SBR09 Claim Filing

Indicator Code

MC

Subscriber Name 2010BA NM102 Entity Type

Qualifier

‘1’ Person


Code Qualifier

‘MI’ Member

Identification




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Number


Code

USVI Medicaid 10

digit Recipient

Number


Organization

Name

VI_MMIS_4_DXCMS


Code Qualifier

‘PI’ Payer

Identification


Code

VI_MMIS_4_DXCMS

Claim Information 2300 CLM01 Claim Submitter’s

Patient Account /

Identifier Number

Patient Control

Number


or Response Code

‘Y’ Yes


or Response Code

‘Y’ Yes

Discharge Hour 2300 DTP01 Date Time Period

Discharge Hour

‘096’

Claim Information 2300 DTP02 Date Time Period

Format Qualifier

‘TM’

Admission Date/Hour 2300 DTP01 Date Time

Qualifier

‘435’

Admission Date/Hour 2300 DTP02 Date Time Period

Format Qualifier

‘D8’ or ‘DT’

Admission Date/Hour 2300 DTP03 Date Time Period

Institutional Claim Code 2300 CL101 Admission Type

Code

Institutional Claim Code 2300 CL102 Admission Source

Code

Institutional Claim Code 2300 CL103 Patient Status

Code

Prior Authorization or

Referral Number

2300 REF01 Reference

Identification

Qualifier

‘G1’ Prior

Authorization

Number

Prior Authorization or

Referral Number


Identification

Assigned Prior

Authorization




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Prior

Authorization

Number

Number

Other Diagnosis Code 2300 HI01-2 Industry Code

Diagnosis Code

Use appropriate

Reference

Principal Procedure

Information

2300 HI01-1 Code List

Qualifier Code

‘BF’ International

Classification of

Diseases Clinical

Modification (ICD-

9CM)

Principal Procedure

Information


Principal

Procedure Code

Principal Procedure

Code

Other Procedure

Information

2300 HI01-1 Code List

Qualifier Code

‘BQ’ International

Classification of

Diseases Clinical

Modification (ICD-9-

CM) Procedure

Other Procedure

Information


Procedure Code

Other Procedure Code

Other Procedure

Information

2300 HI01-4 Date Time Period

Procedure Date

Attending Physician

Name

2310A NM108 Identification

Code Qualifier

‘XX’ National

Provider ID

Attending Physician

Name

2310A NM109 Identification

Code

Attending Physician


Attending Physician

Name

2310A PRV01 Provider Code ‘AT’ Attending

Attending Physician

Name

2310A PRV02 Reference

Identification

Qualifier

‘PXC’ Health Care

Provider Taxonomy

Code

Attending Physician

Name

2310A PRV03 Reference

Identification

Provider Taxonomy

Code


Code Qualifier

‘XX’ National

Provider ID


Code

Referring Provider


SBR-Other Subscriber

Information


Indicator Code

Please ensure to

use the correct

indicator code(s)

when billing VI

Medicaid as a




Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

secondary or

tertiary payer.

Do not send ‘MC’ in

this

Position/Segment

for secondary or

tertiary claims.

Valid values are;

‘11’ – Other

NonFederal

Programs


Provider

Organization

(PPO)


Service (POS)

14 – Exclusive

Provider

Organization

(EPO) ‘15’ – Indemnity

Insurance

‘16’ – Health

Maintenance

Organization

(HMO) Medicare

Risk

‘17’ – Dental

Maintenance

Organization


Medical


Blue Shield



Insurance Co



Employees

Program

‘HM’ – Health

Maintenance

Organization





Loop Name Loop

ID

Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Medical

‘MA’ – Medicare Part A


Part B

‘OF’ – Other

Federal Program



Affairs Plan


Compensation

health Claim


Defined

Institutional Service Line 2400 SV202 Composite

Medical

Procedure

Identifier

Required for all

Outpatient claims

Institutional Service Line 2400 SV207 Monetary Amount

Line Item Denied

Charge or

NonCovered

Charge Amount


Group Code


Reversals



Reason Code

For adjustment

reason codes see

http://wpc-edi.com


Adjusted Amount

Line Level


Units – Line

Level

http://wpc-edi.com/

http://wpc-edi.com/

http://wpc-edi.com/

http://wpc-edi.com/




837 DENTAL TRANSACTION COMPANION GUIDE

The 837 Institutional Versions used in creating the guide.

Health Care Claim: Dental 005010X224 May 2006

Health Care Claim: Dental 005010X224A1 October 2007

Health Care Claim: Dental 005010X224A2 June 2010

Loop Name Loop ID Field

Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Version/Release/

Industry

Identifier Code

GS08 Identification

Code

005010X224A2

Subscriber

Hierarchical

Level

2000B HL04 Hierarchical

Level

‘0’

No subordinate HL

Segment in the

Hierarchical

Structure

Subscriber

Hierarchical

Level

2000B SBR09 Claim Filing

Indicator Code

“MC” Medicaid

Subscriber

Name

2010BA NM102 Entity Type

Qualifier

“1” Person

Subscriber

Name

2010BA NM108 Identification

Code Qualifier

“MI” Member

Identification

Number

Subscriber

Name

2010BA NM109 Identification

Code

USVI Medicaid

10 digit

Recipient

Number


Organization

Name

VI_MMIS_4_DXCMS


Code Qualifier

“PI” Payer Identification


Code

VI_MMIS_4_DXCMS

Claim

Information

2300 CLM01 Claim Submitter’s

Patient Account

Patient Control Number

Claim

Information

2300 CLM11-1 Related Causes

Code

“AA” – Auto Accident

“OA” – Other Accident

Claim

Information

2300 CLM12 Special Program

Code

“01‟ EPSDT





Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Referral

Identification


Identification

Qualifier

“G3” Prior

Authorization

Number

Referral

Identification


Identification

Referral Number

Assigned Prior

Authorization

Number

SBR-Other

Subscriber

Information


Indicator Code

Please ensure to use

the correct indicator

code(s) when

billing VI

Medicaid as a

secondary or

tertiary payer.

Do not send

‘MC’ in this

Position/

Segment for

secondary or tertiary

claims.

Valid values

are;

‘11’ – Other

Non-Federal

Programs


Provider

Organization

(PPO)


Service (POS)

14 – Exclusive

Provider

Organization (EPO)

‘15’ –

Indemnity Insurance

‘16’ – Health

Maintenance

Organization

(HMO)

Medicare Risk

‘17’ – Dental

Maintenance

Organization






Position/

Segment

Data Element

Name/Page

Number from

Implementation

Guide

Valid Values

And/or

Comments

A B C D E

Medical


Blue Shield



Insurance Co



Employees Program

‘HM’ – Health

Maintenance

Organization


Medical

‘MA’ – Medicare

Part A


Part B

‘OF’ – Other

Federal Program



Affairs Plan


Compensation

health Claim


Defined

Other

Subscriber

2320 AMT02 Monetary

Amount Payer

Paid Amount

Other Insurance paid

Amount


Group Code


Reversals



Reason Code

For adjustment reason

codes see

http://wpc-edi.com


Adjusted Amount

Line Level


Units – Line

Level

http://wpc-edi.com/

http://wpc-edi.com/

http://wpc-edi.com/

http://wpc-edi.com/




ATYPICAL PROVIDERS

Atypical Providers (performing non-health care services) who will be permitted to bill using their

existing Medicaid ID numbers.

The EDI formatting location of Billing, Referring, and Rendering Provider Information is dependent

upon the situation being billed. Below are the circumstances and EDI billing locations of this

information.

Billing Provider Location

This is used when the Billing Provider is a servicing provider only and/or if the Billing Provider is the

same as the Pay-To Provider.

Loop Header Loop Reference Definition Values

Billing Provider Tax

Identification

2010AA REF01 Reference Identification

Qualifier

‘EI’ or

‘SY’

Billing Provider Tax

Identification

2010AA REF02 Billing Provider Additional

Identifier

Billing Provider

Secondary

Identification

2010BB REF01 Reference Identification

Qualifier

‘G2’

Billing Provider

Secondary

Identification

2010BB REF02 Billing Provider Additional

Identifier

Billing

Medicaid

Provider

Number

Rendering

Provider Name

2310B REF01 Reference Identification

Qualifier

‘G2’

Rendering

Provider Name

2310B REF02 Reference Identification

Rendering

Medicaid

Provider

Number




ADDITIONAL PROVIDER INFORMATION

Attending Physician NPI Location

Required when the claim being billed is for an Inpatient Bill Type.

VI Medicaid does not require the use of NPI when billing the Attending Physician number. Therefore

the NPI “OR” Legacy ID may be submitted when billing the Attending Physician ID.

Loop 2310A


Position/

Segment

Data Element Name/Page

Number from

Implementation Guide Valid Values

And/or

Comments

Attending Physician

Name

2310A NM108 Identification Code Qualifier ‘XX’

National

Provider ID

Attending Physician

Name

2310A NM109 Identification Code Attending

Physician

National

Provider ID

Or


Position/

Segment

Data Element Name/Page

Number from

Implementation Guide Valid Values

And/or

Comments

Attending Physician

Secondary

Identification

2310A REF01 Reference Identification

Qualifier

‘G2’

Medicaid

Provider

Number

Attending Physician

Secondary ID

2310A REF02 Reference Identification

Medicaid

Provider

Number




APPENDICES

Implementation Checklist

The Health PAS-OnLine web portal user guides contains all necessary steps for going live with DXC

Technology in submitting specified EDI transactions, and receiving EDI responses, including the

5010 837. It also covers the following categories:

Register for a Trading Partner ID

Test with DXC Technology

The user guides can be found at https://www.vimmis.com/User%20Guides/Forms/AllItems.aspx.

Transmission Examples

TA1 Interchange Acknowledgement

The TA1 interchange acknowledgement is used to verify the syntactical accuracy of the envelope of

the X12 interchange. The TA1 interchange will indicate that the file was successfully received, as

well as indicate what errors existed within the envelope segments of the received X12 file.

The structure of a TA1 interchange acknowledgement depends on the structure of the envelope of

the original EDI document. When the envelope of the EDI document does not contain an error then

the interchange acknowledgement will contain the ISA, TA1, and IEA segments. The TA1 segment

will have an Interchange Acknowledgement Code of ‘A’ (Accepted) followed by a three-digit code of

‘000’ which indicates that there were not any errors.

If the EDI document contains an error at the interchange level, such as in the Interchange Control

Header (ISA) segment or the Interchange control trailer (IEA), then the interchange

acknowledgement will also only contain the ISA, TA1, and IEA segments. The TA1 segment will

have an Interchange Acknowledgement Code of ‘R’ (Rejected) which will be followed by a three-

digit number that corresponds to one of the following codes:

Code Description

000 No error

001 The Interchange Control Number in the Header and Trailer Do Not Match. The Value

From the Header is Used in the Acknowledgment

002 This Standard as Noted in the Control Standards Identifier is Not Supported

003 This Version of the Controls is Not Supported

005 Invalid Interchange ID Qualifier for Sender

006 Invalid Interchange Sender ID

009 Unknown Interchange Receiver ID

010 Invalid Authorization Information Qualifier Value (ISA01 is not ‘00’ or ‘03’)

012 Invalid Security Information Qualifier Value

013 Invalid Security Information Value

018 Invalid Interchange Control Number Value

019 Invalid Acknowledgment Requested Value

https://www.vimmis.com/User%20Guides/Forms/AllItems.aspx




Code Description

020 Invalid Test Indicator Value

021 Invalid Number of Included Groups Value

023 Improper (Premature) End-of-File (Transmission)

024 Invalid Interchange Content (e.g., Invalid GS Segment)

025 Duplicate Interchange Control Number

999 Implementation Acknowledgement for Health Care Insurance

The ASC X12 999 transaction set is designed to report only on conformance against a Technical

Report Type 3line (TR3).

The 999 is not limited to only Implementation Guide (TR3) errors. It can report standard syntax

errors, as well as Implementation Guide (TR3) errors.

The 999 cannot be used for any application level validations.

The ASC X12 999 transaction set is designed to respond to one and only one functional group (i.e.

GS/GE), but will respond to all transaction sets (i.e. ST/SE) within that functional group.

This ASC X12 999 Implementation Acknowledgement cannot be used to respond to any

management transaction sets intended for acknowledgements, i.e. TS 997 and 999, or interchange

control segments related to acknowledgments, i.e. TA1 and TA3.

Each segment in a 999 functional acknowledgement plays a specific role in the transaction. For

example, the AK1 segment starts the acknowledgement of a functional group. Each AKx segment

has a separate set of associated error codes.

The 999 functional acknowledgements include, but are not limited to, the following required

segments:

ST segment—Transaction Set Header

AK1 - Functional Group Response Header

AK2 - Transaction Set Response Header

IK3 – Error Identification

CTX – Segment Context

CTX – Business Unit Identifier

IK4 – Implementation Data Element Note

CXT – Element Context

IK5 – Transaction set response trailer

AK9 - Functional Group Response Trailer

SE -Transaction Set Trailer

For additional information regarding the 999 transaction, see the Implementation

Acknowledgement Section of the ASC X12 Standards for EDI Technical Report Type 3 Technical

Report Type 3 line for the transaction you are submitting.

824 Application Advice

This transaction is not mandated by HIPAA, but will be used to report the results of data content

edits of transaction sets. It is designed to report rejections based on business rules such as invalid

diagnosis codes, invalid procedure codes, and invalid provider numbers. The 824 Application Advice




does not replace the 999 or TA1 transactions and will only be generated by Health PAS if there are

errors within the transaction set.

The 824 acknowledgment is divided into two levels of segments: header and detail.

The header level contains general information, such as the transaction set control

reference number of the previously sent transaction, date, time, submitter, and receiver.

The detail level reports the results of an application system’s data content edits.

The 824 Application Advice includes, but is not limited to following segments and their roles:

Header Segments:

ST segment—Transaction Set Header

BGN segment—Beginning Segment

N1 segment—Submitter Name

N1 segment—Receiver Name

Detail Segments:

OTI segment—Original Transaction Identification

TED segment—Error or Informational Message Location

RED segment—Error or Informational Message

SE segment—Transaction Set Trailer

The Health PAS Application outputs the following errors in the TED segment of the 824 Application

Advice:

Code

TED01

Description

TED02

O Missing or Invalid Issuer Identification

P Missing or Invalid Item Quantity

Q Missing or Invalid Item Identification

U Missing or Unauthorized Transaction Type Code

006 Duplicate

007 Missing Data

008 Out of Range

009 Invalid Date

010 Total Out of Balance

011 Not Matching

012 Invalid Combination

024 Other Unlisted Reason

027 Customer Identification Number Does not Exist

815 Duplicate Batch

848 Incorrect Data

DTE Incorrect Date

DUP Duplicate Transaction

ICA Invalid Claim Amount

IID Invalid Identification Code

NAU Not Authorized

UCN Unknown Claim Number




Business Rejection Report

Health PAS also produces a readable version of the 824 called the Business Rejection Report (BRR).

This report helps to facilitate the immediate correction and re-bill of claims rejected during HIPAA

validation.

Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to DXC Technology and its

providers. Typical question would involve a discussion about code sets and their effective dates.

See http://www.vimmis.com for answers to frequently asked questions.

Change Summary

The companion guide was updated to provide addition business scenario information for copayment

on the transmission response file.

Version Date Author Action/Summary

1.0 11/01/2012 USVI EDI Created to reflect 5010

1.1 02/06/2013 M. Searcy QA Review

1.2 11/30/2018 K. Banik DXC Rebranding






Version Date Author Action/Summary

1.3 12/03/2018 Kim Stoudenmire QA of DXC Rebranding

1.4 05/01/2019 Katie Banik Per CR 2468, Updated Receiver ID

from VI_MMIS_4MOLINA to VI_MMIS_4_DXCMS

Updated TRANSACTION SPECIFIC INFORMATION

1.5 05/22/2019 Kim Stoudenmire QA review of updates for CR2468

Documents

HEALTH CARE CLAIM Companion Guide - vimmis.com Guides/USVI 5010... · Health Care Claim transactions. Refer to the “Health Care Claims (837)” ASC X12N Implementation Guide for