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5010 Transactions
Health New England X12 837 5010 Claims Companion Guide

HNE has developed the following Companion Guide as a support tool for our Trading Partners when submitting electronic HIPAA 5010 Professional and Institutional claims.  HNE accepts such claims in the format described in the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, ASC X12 837, version 005010.  (We also may refer to this as the TR3, or "the Guide.") HNE will accept Professional and Institutional claims in the format consistent with forms 005010X222A1 and 005010X223A2 respectively, both published in June 2010.  These Guides may be purchased from the Washington Publishing Company at http://www.wpc-edi.com.

Our Trading Partners may select from several different options for filing claims electronically: 

  • Clearinghouses – See http://hne.com/HNE_Providers/Forms/2010/Clearinghouse_List_final.pdf for a complete list of Clearinghouse that HNE transacts with.
  • Providers can submit files through HNEDirect, our secure website (HNE providers only).
  • All Trading Partners can submit files to our FTP server
  • HNE can retrieve files from a Trading Partner's FTP server.
  • HNE can receive and send files through NEHEN if you are registered with NEHEN.  See http://www.nehen.com for more information on membership benefits.

 

If you are not filing your claims electronically and you would like more information, please contact HNE's Provider Relations Department 413-787-4000 extension 5000 or by email at provideroperations@hne.com.  

EDI files are processed on business days between 8:00 AM and 1:00 PM. Files received after 1:00 PM will be processed at 8:00 AM the next business day.

Health New England follows the Basic Character Set found in from the HIPAA 837 Implementation Guide Table B.1 in appendix B.1.1.2.2 Basic Character Set.

Envelope Structure

We understand that we are only one of your many Trading Partners – we do not expect you to customize your content just for us. HNE uses ECMap® and ECGateway® from Sybase to process EDI (X12) transactions.  Because of the flexibility of this software, we have a limited number of filing requirements. These are described below:

Segments per line: We do not require EDI files with one segment per line.  EDI files may be submitted as one continuous string of text.

Delimiters: We have no standard or preference for delimiters. If you have no standard or preference, follow the TR3.  See Table B.5 in Appendix B.1.1.2.5

Control Segments: Please use the standard EDI file guidelines described in the HIPAA Implementation Guide, Appendix C for control segments.

ISA Segment: The ISA Segment is the first line that HNE receives in an EDI file.  Some elements within each ISA segment have a number of possible values.  Please use the following values for each ISA element:

ISA01

00

ISA02

10 spaces

ISA03

00

ISA04

10 spaces

ISA05

HNE can accept all other codes listed in Appendix C.1, however HNE would prefer 30.  Please do not use the value ZZ. 

ISA06

Assign the value based on the qualifier in ISA05. If you use 30 in ISA 05, please use your U.S. Federal Tax Identification Number.

ISA07

HNE can accept 01 or 30; however, HNE would prefer 30.  Please do not use the value ZZ. 

ISA08

Based on which qualifier you use in ISA07, these values can be used:

 

Qualifier

Value

01

152427324

30

042864973

 

 

For other ISA elements, please follow the implementation guide.

GS Segment: Please use the following values for each GS element.

GS01

HC

GS02

HNE can accept anything, but prefer to mimic what is in ISA06

GS03

HNE can accept anything, but prefer to mimic what is in ISA08

For other GS elements, please follow the implementation guide.

Control Numbers:  At least one of the ISA, GS and ST control numbers must increment from one day to the next. Although this is left to your preference, please note below the effect that this may have on the 997 Functional Acknowledgment/999 Implementation Acknowledgement.

997 Functional Acknowledgement/999 Implementation Acknowledgement transaction: The 997 Functional Acknowledgment/999 Implementation Acknowledgement transaction does not reflect the ISA control number received on the 837 Claim. If you want to use the 997/999 to reconcile the 837 (or any other transaction we do in the future) then the GS and/or ST control numbers should increment from day to day.

Multiple submissions: There are no restrictions for multiple submissions:

  • HNE can accept multiple ISA-IEA envelopes within a single file.
  • HNE can accept multiple GS-GE envelopes within a single ISA-IEA interchange.
  • HNE can accept multiple ST-SE envelopes within a single GS-GE functional group.
  • HNE can accept multiple billing providers (2000 loop) within a single ST-SE transaction.

Compliance Test

All files must pass a stringent TR3 compliance test in order for the 837 transaction to be accepted. This test interprets the "gray box" information in the TR3. A single error will result in the rejection of the entire transaction (ST-SE envelope).

Following the compliance test, the 837 transaction will trigger a 997 Functional Acknowledgment/999 Implementation Acknowledgement, either accepting the transaction or rejecting it with an explanation. The 997 Functional Acknowledgement is available for purchase from Washington Publishing Company at http://www.wpc-edi.com.

At this time HNE cannot generate a TA1 Interchange Acknowledgment.

At this time HNE does not generate a 277CA Health Care Claim Acknowledgement in response to an 837.

Claims Content

2000C Patient Name Loop – For 5010 this loop is not to be used for HNE claims. Every HNE member has a unique 11-digit member identification number. This number can only be used in the 2000B Subscriber Name Loop.

The TR3 Notes for 2000B read:

If a patient can be uniquely identified to the destination payer in Loop ID-2010BB by a unique Member Identification Number, then the patient is the subscriber or is considered to be the subscriber and is identified at this level, and the patient HL in Loop ID-2000C is not used.

The TR3 Notes for 2000C read:

If a patient is a dependent of a subscriber and can be uniquely identified to the payer by a unique Identification Number, then the patient is considered the subscriber and is to be identified in the Subscriber Level.

Transactions containing the 2000C loop will be rejected.

Member Identification Number in 2000B, NM0109.

You must use the HNE-Issued Member Identification Number. This number is 11 digits and starts with an 8 or a 9.

You must not use Social Security Number.

You must not use Medicare Number.

You must not use Medicaid Number.

PRV segment: HNE can accept provider taxonomy codes, but they are not required.

HNE Requirements:

·      For All Claims: All monetary amounts (anywhere in the transaction) must be less than $10 million. Monetary amounts of $10 million or more will be left truncated. (Ex: $12,345,678 becomes $2,345,678.) This is likely to be an issue for claim total charges. Please contact HNE Provider Relations if you need to submit a claim with a monetary amount of $10 million or more.

  • For Institutional Claims, the SV20201 (Procedure Code Qualifier) element is situational, but when used must contain the value "HC" (HCPCS).  
  • For Institutional Claims, the SV203 (Line Item Charge Amount) element may not be a negative amount.
  • For Institutional Claims, the SV205 (Quantity alias Service Unit Count) element must be a positive number. Zero and negative numbers are not allowed. Fractions are not allowed.
  • For Professional Claims, the SV10101 (Procedure Code Qualifier) element must contain the value "HC" (HCPCS).  
  • For Professional Claims, the SV102 (Line Item Charge Amount) element may not be a negative amount.

·      For Professional Claims, the SV104 (Quantity alias Service Unit Count) element must be a positive number. Zero and negative numbers are not allowed. Ambulance mileage may be submitted in tenths of a mile. Fractions are not otherwise allowed

·      For Professional Claims: Use of Billing Provider and Service Facility Location has changed from 4010. Follow the 5010 TR3 when using these loops. Billing Provider is the lowest sub-part within your provider organization (e.g. Department of Cardiology.) Service Facility is outside your provider organization (e.g. Anesthesia services at a hospital.) See section 1.10, National Provider Identifier Usage within the HIPAA 837 Transaction, of the TR3.

 

Claims that meet the above requirements are subject to HNE membership eligibility and coverage criteria.

At this time, HNE cannot process secondary COB claims. When another payer has primary responsibility and has made payment, please submit the claim on paper (CMS-1500 or UB-04) with a copy of the primary payer's Explanation of Payment.

At this time HNE cannot process corrections to previously submitted claims. When you need to correct a previously submitted claim please submit the claim on paper (CMS-1500 or UB-04). Attach a note indicated the claim# of the previously submitted claim and the nature of the correction.

For each trading partner and each transaction, we keep track of primary and secondary contacts, including name, address, phone, and e-mail. Please provide this in an e-mail to ecgwsupport@hne.com.

 

 

Voided Claims

After a transaction has passed the compliance test it is translated and loaded to HNE's claims adjudication system. There are several conditions that prevent a claim from being adjudicated. These claims are voided and reported to the provider on a letter. Voided claims are not reported on an Explanation of Payment or an 835.

Void reasons:

01   REJECTED: PATIENT NOT ENROLLED WITH HEALTH NEW ENGLAND

The member# submitted is not a valid member#.

02   REJECTED: INVALID IRS NUMBER REPORTED ON CLAIM RECORD

The IRS# submitted is not a valid IRS#, or is not the IRS# for this provider.

03   REJECTED: A POSITIVE VALUE IS REQUIRED IN QTY/SERVICE UNIT COUNT FIELD

The Quantity (SV104 or SV205) must be a positive number. Zero and negative numbers are not allowed.

04   REJECTED: SERVICE DATE NOT WITHIN FROM AND THROUGH DATES

For institutional claims, the service level date of service must be within the claim level statement dates.

05   REJECTED: SERVICE DATE CANNOT BE GREATER THAN RECEIVED DATE

Claims may not be submitted prior to the date of service.

06   REJECTED: INVALID OR MISMATCHING POA

For Institutional claims the Present on Admission code must be valid.

07   REJECTED: INVALID DIAGNOSIS CODE

Diagnosis codes must be valid in ICD9-CM.

08   REJECTED: ANESTHESIA SERVICE BILLED WITH NO MODIFIER

Anesthesia services must have an Anesthesia modifier.

10   REJECTED INVALID / INCOMPLETE CLAIM RECORD RECEIVED

This will be accompanied by a specific description of the claim deficiency.

 

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