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.
