HNE has developed the following Companion Guide as a support tool for the Health Care Claim Payment/Advice, ASC X12 835 version 005010 HIPAA Implementation Guide, First Addenda. The implementation guide is 005010X221A1; published in April  and available from: http://www.wpc-edi.com (free PDF download for registered users.)

HNE will work with our Trading Partners to select the method for transferring claim remittances:

• Organizations within Baystate Health Systems can use our private FTP server over the private network between HNE and BHS.
• HNE can place files on our secure FTP Server for our Trading Partner to pull.
• HNE can send files to your secure 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.
• Clearinghouses – See Clearinghouse under HIPAA for a complete list.

EDI files are processed on Monday nights and are available on Tuesday morning. If a Monday falls on a holiday, the schedule moves forward one day. The holiday schedule for next year is published in mid-December of the current year.

HNE uses ECMap and ECGateway from Sybase to process X12 transactions. This software is very flexible, allowing us to create a wide range of content, though we do have several preferences. Appendix B. of the HIPAA Implementation Guide allows for some flexibility in the format of EDI Control Segments.

Element and sub-element delimiters appear before the element or sub-element. The segment delimiter appears on the end of the preceding line. The next segment will appear on the next line.

Example: SVC*HC>90460*24*24**1~

The default delimiters are:

 

*	Element
>	Sub-element
~	Segment

 

If you use different delimiters we can easily accommodate your requirements.

ISA Interchange Control Header Segment

The ISA segment is the first line that HNE sends 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	01
ISA06	152427324
ISA07	30
ISA08	Your EIN

 

GS Functional

Please use the following values for each GS element:

 

GS01	HP
GS02	152427324
GS03	Your EIN

 

For other GS elements please follow the implementation guide. We can customize these elements to meet your requirements.

Envelope

HNE will create multiple ST-SE envelopes within a single GS-GE, one for each line of business (fully insured and self funded.)

Compliance Test

All files must pass a stringent HIPAA Implementation Guide compliance test before releasing the 835 to you. This test interprets the “gray box” information in the HIPAA Implementation Guides.

Paper Checks and Check Trace Number

At this time HNE cannot produce an EFT or ACH transaction. All payments will be on a paper check. The Check Trace number is in the TRN02 segment and is printed on every check.

HNE can produce an 835 in conjunction with the current paper Explanation of Payment (EOP). The EOP also has the Check Trace number on it. We will only stop printing paper EOPs at your request.

During testing of the 835, HNE usually uses claims and payments from our production environment, but we can use test environments if the need arises.

Transaction Content

Loop 2100

 

In loop 2100, in the CLP segment, the CLP01 element “Patient Control Number” will contain the patient control number from the claim submitted. In most cases we can return up to 20 characters in this element. The exception is claims submitted in 837 Professional format or on CMS-1500 forms, in which case, only up to 12 characters are returned.

Loop 2110

In loop 2110, the CAS segment, we have established a translation from internal codes to standard Claim Adjustment Group Codes and Claim Adjustment Reason Codes. These are described in the    LQ segment. We have established a translation from internal codes to standard Claim Payment Remark Codes. These are described in a separate MS Excel spreadsheet “EXCodesRemarks.XLS”.

Acknowledgements

HNE will accept 997 and 999 acknowledgement transactions. Acknowledgements are not required.

 

997 Functional Acknowledgment

The 997 acknowledges receipt of a file and confirms whether or not the file has successfully passed initial processor edits. The 997 can be used only to report syntactical errors on the based transaction standard. This is an important distinction and a new function provided with version 5010 X12 transactions.

999 Implementation Acknowledgment

The 999 reflects technical problems that must be addressed by the software preparing the EDI transmission. The 999 transaction provides new functionality that will allow a trading partner to report Implementation Guide constrained edits, and edits against the base X12 standard with

their front end editors/translators.

HNE Process to Create 835 Remittance

AMISYS Advance provides support for the HIPAA-mandated ASC X12 835 Health Care Claim Payment/Advice EDI transaction version 005010 (“the 835”). As part of the Claims Payable extract, post and check writer, records are written to several REMIT_tables in the Oracle database. The Create 835 EOP File process, CPP0835, formats these records into a flat file. HNE uses an EDI Translation Map (CPO0100) to create the 835 file.

The 835 reports the difference between what the provider charged and what the health plan paid at the service level. Providers can use this information to reconcile their accounts receivable and verify what payment, if any, can be collected from the patient. All health plans must use standard Claim Adjustment Group Codes (full list follows) and Claim Adjustment Reason Codes (full list at http://www.wpc-edi.com/reference/codelists/healthcare/claim-adjustment-reason-codes/) in the 835. These codes are used in the CAS segment of the 835. HNE only uses CAS segments in the 2110 Service Payment Information loop.

Each health plan must map the AMISYS Advance Paid Equation to the Adjustment Group and Adjustment Reason using the new GA code set.

Claim Adjustment Group Codes

Code Definition for CAS01

CO   Contractual Obligations

• Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.
• Use this code for corrections and reversals to PRIOR claims.
• Use when CLP02=22.

OA   Other adjustments

PI     Payer Initiated Reductions

PR    Patient Responsibility

• Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but no supporting contract exists between the provider and the payer.

CR   Correction and Reversals (NO LONGER VALID)

Each of these Group Codes should be entered as a GA code set (GACO, GAOA, GAPI and GAPR.) The code set keywords will map the Paid Equation Code to the Group Code and the Reason Code.

 

 

The code set keywords will map the Paid Equation Code to the Group Code and the Reason Code.

Paid Equation to Group Code & Reason Code Mapping

Paid Equation Code	Description	Group Code	Reason Code	Description
03	Copay	PR	3	Co-payment Amount
04	Coinsurance	PR	2	Coinsurance Amount
08	Deductible	PR	1	Deductible Amount
12	Third Party Payment   Applied	OA	231	Payment adjusted because charges have been paid by another payer
14	Denied, EX=2L, 3L, LD	OA	23	Payment adjusted because charges have been paid by another payer
18	Amount Paid (Medicare)	OA	23	Payment adjusted because charges have been paid by another payer
42	Discrepancies	OA	123	*Dummy code, should not be sent to providers
06	Discount (PHO User Fee)	CO	104	Managed care withholding
07	Risk Withhold	CO	104	Managed care withholding
14	Denied (all other EX codes)	CO	A1	Non-covered charge(s)
14	Denied, EX=OM, I6, OL	CO	4	The procedure code is inconsistent with the modifier used or a required modifier is missing.
14	Denied, EX=D1, D2, OD	CO	18	Duplicate claim/service
14	Denied, EX= L2, 2L, L3	CO	22	This care may be covered by another payer per coordination of benefits.
14	Denied, EX=M4	CO	27	Expenses incurred after coverage terminated
14	Denied, EX=CL, DW	CO	29	The time limit for filing has expired.
14	Denied, EX=PM, U0, A2	CO	38	Services not provided or authorized by designated (network/primary care) providers
14	Denied, EX=K1, K2, K4, K5, K6, K7, K8, K9, KA, CQ, DH, RT, RU, CA, CG, CK, CM, CU, DN, ES, GA, OB, OS, RI, I1, S3, HP, I4, OU, OT, QV, K0, 75, KP, SK, OF, I2, DW	CO	972	Payment is included in the allowance for another service/procedure
14	Denied, EX=RA, RJ, FR, FO	CO	109	The claim is not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
14	Denied, EX=AM, S7, A0, NI, Q3, AL, NC, DM, BF, IV, A6	CO	197	Precertification/authorization/notification absent

14	Denied, EX=BN, HN, BG, BM, BC	CO	204	This service/equipment/drug is not covered under the patient's current benefit plan.
14	Denied, EX=BJ	CO	119	Benefit maximum for this time period or occurrence has been reached
14	Denied, EX=NP	CO	112	Service not furnished directly to the patient and/or not documented
14	Denied, EX=DK	CO	31	Patient cannot be identified as our insured
14	Denied, EX=NN	CO	34	Insured has no coverage for newborns
14	Denied, EX=BH	CO	9	The diagnosis is inconsistent with the patient's age. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.
19	Amount Fill Fee	CO	91	Dispensing fee adjustment
313	Amount Fee For Service Equivalence	CO	24	Payment for charges was adjusted. Charges are covered under a capitation agreement/managed care plan.
41	Disallow amounts (most EX codes)	CO	454	Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement
41	Disallow, EX=K6, K9, RT	CO	975	Payment is included in the allowance for another service/procedure.
41	Disallow, EX=UO	CO	38	Services not provided or authorized by designated (network/primary care) providers
01	Provider Allow
02	Benefit Allow
25	Prompt payment discount6
26	Late payment interest penalty7
45	Third Party Claim Processor (Claim Check, Code Review) Payment Codes
94	Third Party Claim Processor Payment Codes
97	Third Party Claim Processor Payment Code8

 

¹ 23 is used for these Explanation Codes as the service is covered and normally would be paid if another payer had not already made full payment.
² 97 is used for these Explanation Codes as the service is covered and normally would be paid if it was rendered by itself. These EX codes have a DENY keyword to prevent counters from being created.

³ HNE made up this value. We changed CPP0100.COBOL to look for X in the 2nd byte of CLAIM-TYPE. It will map to 31 instead of 42 (Discrepancies.)
⁴ Up until 4/17/09 we used 42 “Charges exceed our fee schedule or maximum allowable amount.” 42 was discontinued on 6/1/2007.
⁵ 97 is used for these Explanation Codes as the service is covered and would normally be paid if it was rendered by itself. These EX codes have a PAY keyword and the payclass is set to allow zero.
⁶ Prompt payment discount is to be reported in AMT and PLB segments, not a CAS segment.
⁷At this time HNE computes late payment interest penalties outside of AMISYS Advance for commercial claims. For Medicare Advantage HNE uses the AMISYS Advance late payment function. Interest in supposed to be reported in AMT and PLB segments, not a CAS segment.
⁸ HNE does not use a Third Party Claim Processor.

 

At this time HNE doesn’t use Provider Allow or Benefit Allow as part of the paid equation, so we have not mapped them.

We have not yet determined a Reason Code to use with 42 “Discrepancies”. Testing to date has revealed that capitated services (claim type ending in X) will use 42 in this way:

Charge – Disallow – Copay – Discrepancy = Paid = 0

e.g. $100 - $17 - $10 - $73 = 0

 

Inappropriate use of the AMT action on the service level re-adjudication and adjustment screens may lead to FFS services that are out-of-balance; the discrepancy will be used to balance these services.