HAP Midwest Health Plan HIPAA Transaction … · HAP Midwest Health Plan HIPAA Transaction ... authorization information and delimiters. ... Code HAP Midwest Health Plan ID will be
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Disclosure Statement This companion document is the property of HAP Midwest Health Plan and is for use solely in your capacity as a trading partner of health care transactions with HAP Midwest Health Plan. It is incorporated by reference in the EDI Trading Partner Agreement.
Preface This document describes the components that are related to the file for the 277CA (Claims Acknowledgement) for Professional and Institutional EDI transactions.
SCOPE ............................................................................................................ 5 REFERENCES ............................................................................................................. 5 ADDITIONAL INFORMATION ............................................................................. 6
2 GETTING STARTED .................................................................................................... 6 WORKING WITH HAP MIDWEST HEALTH PLAN .......................................... 6 TRADING PARTNER REGISTRATION .............................................................. 6 CERTIFICATION AND TESTING OVERVIEW ................................................... 6
3 TESTING WITH THE PAYER ....................................................................................... 6 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ............................................. 6
PROCESS FLOWS ............................................................................................. 6 COMMUNICATION PROTOCOL SPECIFICATIONS ......................................... 7 PASSWORDS ..................................................................................................... 7
5 CONTACT INFORMATION ............................................................................................... 7 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE ......................... 7 PROVIDER SERVICE NUMBER ..................................................................... 7 APPLICABLE WEBSITES/E-MAIL ................................................................... 8
ENVELOPE AND FUNCTIONAL GROUP STRUCTURE ..................... 8 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ........................................... 8
STC COMPOSITE AND CODE USE RULES ..................................................... 8 MEMBER ID RULES ........................................................................................ 9 MAXIMUMS/LIMITATIONS.................................................................................. 9 REJECTED TRANSACTIONS/ACKNOWLEDGMENTS .................................... 9
DISCLAIMERS .............................................................................................. 13 10 TRANSACTION SPECIFIC INFORMATION ............................................................. 13
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
1 INTRODUCTION This section 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 HAP Midwest Health Plan 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 HAP Midwest Health Plan
In addition to the row for each segment, one or more additional rows are used to describe HAP Midwest Health Plan’s usage for composite and simple data elements and for any other information. Notes and comments specify detailed information. In the example below, a note about a code value about the segment is shown.
TR3 Page #
Loop ID Segment Data Element
Data Element Name
Business Rules/Notes
47 2100B NM1 - INFORMATION RECEIVER NAME
NM101 Name Last or Organization Name
Information Receiver’s name will be returned
SCOPE
The Health Insurance Portability and Accountability Act-Administration Simplification (HIPAA-AS) requires HAP Midwest Health Plan to comply with the electronic data interchange standards for health care as established by the Department of Health and Human Services and Medicare requirements for CMS.
This document is intended for use as a companion to the HIPAA-mandated ASC X12N/005010X214 277 TR3, dated January 2007. Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the noted HIPAA TR3 published by Washington Publishing Company.
This guide should not be confused with the 276/277 Claims Status Request and Response implementation.
The 277CA transaction set is generated for a submitter who is already successfully submitting 837 claim (professional/institutional) transactions. This document contains HAP Midwest Health Plan’s specifications for the transaction set as well as contact information and key points.
REFERENCES
To obtain any or all of the HIPAA mandated 005010 ASC X12 TR3s, please visit X12’s website http://store.x12.org/store/, or Washington Publishing Company’s website http://www.wpc-edi.com
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
To obtain Health Care Code Lists, please refer to Washington Publishing Company’s website:
http://www.wpc-edi.com/reference/ . The Washing ton Publishing Company’s website provides the Claim Status codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ and
Claim category codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status- category-codes/ for 277 Claims acknowledgement implementation.
Visit http://www.michigan.gov/mdch/ for Michigan Department of Community Health information and instructions.
For Medicare-Medicaid updates refer to http://www.cms.gov/
For Core Rules HIPAA 5010 updates refer to information on http://www.caqh.org/COREv5010.php
ADDITIONAL INFORMATION
Additional information will be provided to trading partners upon request.
2 GETTING STARTED WORKING WITH HAP MIDWEST HEALTH PLAN
277CA is the unsolicited electronic claim acknowledgement in ASC X12N 5010 x214 format. The transaction identifies claims that are accepted as well as claims that were rejected along with claim status codes that indicate the errors. Claims acknowledgement transaction set will be generated along with the 5010 999 Acknowledgement transaction set for trading partners that submit V5010 EDI transactions. In addition, HAP Midwest Health Plan will continue to return the EDI Claim Errors report.
To receive more information or ask questions, please contact Customer Service at 888-654-2200. HAP Midwest Health Plan website www.midwesthealthplan.com/ContactUs.aspx lists additional contact information.
A 277CA acknowledgement is not a guarantee of payment. The status information provided is based on the claim’s characteristics at the time the claim transactions are processed.
TRADING PARTNER REGISTRATION
Providers must complete a HAP Midwest Health Plan Trading Partner Agreement (TPA) prior to submitting V5010 EDI transactions.
CERTIFICATION AND TESTING OVERVIEW
HAP Midwest Health Plan does not require or provide certification for its trading partners.
3 TESTING WITH THE PAYER 277 Claims Acknowledgement implementation will be tested with new trading partners as part of the 5010 EDI transactions submissions testing. Trading Partners should submit test files containing a minimum of 25 test claims that accurately represent the type of claims that will be submitted in production.
4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
To receive the 277 Claim Acknowledgement transactions you must be a registered user with a password and already be submitting HIPAA-compliant 837 files (professional and/or institutional) directly to HAP Midwest health Plan.
COMMUNICATION PROTOCOL SPECIFICATIONS
Please refer to the HAP Midwest Health Plan Providers Administrative Manual for information regarding:
- Submitter setup and trading partner B2B testing
- Direct upload to HAP Midwest Health Plan using HTTPS secure file upload
- Secure FTP submission
- Interchange Acknowledgement (999) transaction
PASSWORDS
HAP Midwest Health Plan requires a password to submit requests. The password could be set up after trading partner agreements have been signed.
5 CONTACT INFORMATION EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE
Technical assistance will be provided upon request. For questions regarding 277CA transactions, please send email to [email protected] and type in “edi277CA” as the prefix in the Subject field for expedited assistance.
PROVIDER SUPPORT NUMBER
HAP Midwest Health Plan: (313)-664-8763
APPLICABLE WEBSITES/E-MAIL
HAP Midwest Health Plan website www.midwesthealthplan.com
Additional contact information is listed at http://www.midwesthealthplan.com/ContactUs.aspx
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
6 CONTROL SEGMENTS/ENVELOPES ISA-IEA – ASC X12N 277 (005010X214) – 277 TRANSACTION INTERCHANGE ENVELOPE AND FUNCTIONAL GROUP STRUCTURE
This section describes HAP Midwest Health Plan’s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information and delimiters.
TR3 Page
#
277 Loop ID
277 Segment
277Data Element
277 Data Element Name
Business Rules/Notes
C.4 ISA ISA – Interchange Control Header
ISA05 Interchange ID Qualifier
“ZZ” will be shown
C.5 ISA ISA – Interchange Control Header
ISA06 Interchange Sender ID
ID that corresponds to the Receivers ID on the 837 will be present
C.5 ISA ISA – Interchange Control Header
ISA07 Interchange ID Qualifier
“ZZ” will be shown
C.5 ISA ISA – Interchange Control Header
ISA08 Interchange Receiver ID
Sender ID that is on the corresponding 837 will be shown
C.6 ISA ISA – Interchange Control Header
ISA15 Usage Indicator “P” for production/”T” for test
C.7 GS GS – Functional Group Header
GS02 Application Sender’s Code
HAP Midwest Health Plan ID will be present
C.7 GS GS – Functional Group Header
GS03 Application Receiver’s Code
ID mutually agreed for transmissions will be shown
C.9 GE GE – Functional Group Trailer
GE01 Number of Transaction Sets Included
Total number of transaction sets included in the functional group will be listed
C.9 GE GE – Functional Group Trailer
GE02 Group Ctrl Number The number sender assigned is shown
HAP Midwest Health Plan’s utilizes the following characters as delimiters on outgoing 277CA transactions.
Delimiters/Separators Character Description
Asterisk * Data element separator
Carat ^ Repeating data element separator
Colon : Composite data element separator
Tilde ~ Terminator
7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS STC COMPOSITE AND CODE USE RULES
HAP Midwest Health Plan supports the following use of composites and codes within the STC segment. The STC segment contains the composite of three STCs, STC01, STC10 and STC11.
• STC01 is required and displays the Acknowledgement Code Status code and entity codes as they apply.
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
• STC10 and STC11 are situational and provide additional clarification to STC01 displaying additional status and entity codes. For example, when Billing Provider’s NPI is not valid, the status codes will be shown utilizing STC10-1, STC10-2 and STC10-3 fields. STC*A7:21*20140825*U*1469.25******A7:562:85~
• Multiple STC segments will be reported for unrelated status codes
MEMBER ID RULES
Member ID is 10 digits Beneficiary ID for MEDICAID, Healthy Michigan Plan and ABW members (0012345678), 9 digits ID for HAP Midwest Advantage Medicare members (000991234), 9 digits ID for Wayne County Health Choice Members (120012345), and alpha-numeric ID for Macomb Care Connect (B0502001).
MAXIMUMS/LIMITATIONS This implementation is intended to support use in batch mode.
REJECTED TRANSACTIONS/ACKNOWLEDGMENTS
Transactions that contain an unauthorized submitter identification number, invalid submitter/provider combinations or are HIPAA non-compliant are rejected and 999 transaction(s) will be returned as defined in the 837 EDI process. The 999 transaction(s) will specify the rejection with error code(s).
8 ACKNOWLEDGEMENTS AND ERROR CODES Rejection Criteria/Error Messages on the 277CA Acknowledgement
Code Claim Status Category Description
A0 Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity. A1 Acknowledgement/Receipt – The claim/encounter has been received.
A2 Acknowledgement/Receipt – The claim/encounter has been received.
A3 Acknowledgement/Returned as unprocessable claim – The claim/encounter has been rejected. The claim must be resubmitted.
A4 Acknowledgement/Not Found – The claim/encounter cannot be found
A6 Acknowledgement/Rejected for Missing Information – The claim/encounter is missing the information specified in the Status details and has been rejected
A7 Acknowledgement/Rejected for Invalid Information – The claim/encounter has invalid information as specified in the Status details and has been rejected.
A8 Acknowledgement/Rejected for relational field in error.
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
9 TRADING PARTNER AGREEMENTS An EDI Trading Partner is defined as any provider, billing service or clearing house that transmits to and receives electronic data from HAP Midwest Health Plan.
HAP Midwest Health Plan has EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.
DISCLAIMERS
This document has been prepared as a HAP Midwest Health Plan specific companion document to ASC X12N 277 (005010X214) implementation guide and to provide instructions to trading partners for the data elements. This companion guide document supplements, but does not contradict any requirements in the implementation guide.
10 TRANSACTION SPECIFIC INFORMATION ASC X12N 277 (005010X214) – 277 TRANSACTIONS
The following section addresses specific information HAP Midwest Health Plan will return within the ASC X12N 277 (005010X214) 277 Transaction. This information should be used in conjunction with the ASC X12N 277 (005010X214) 277 TR3.
TR3 Page
#
277 Loop
277 Segment
277Data Element
277 Data Element Name
Business Rules/Notes
38 2100A NM1 - INFORMATION SOURCE NAME
NM101 Entity Identifier Code
‘PR” will be returned
38 2100A NM1 - INFORMATION SOURCE NAME
NM103 Name Last or Organization Name
“HAP MIDWEST HEALTH PLAN.
INC” will be returned
38 2100A NM1 - INFORMATION SOURCE NAME
NM108 ID Code Qualifier
“PI” will be returned
39 2100A NM1 - INFORMATION SOURCE NAME
NM109 Identification Code
“MHP77” will be returned
40 2200A TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER
TRN02 Reference Identification
Unique trace number that identifies transaction will be returned
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
47 2100B NM1 - INFORMATION RECEIVER NAME
NM103 Name Last or Organization Name
Information receiver’s name will be returned
48 2100B NM1 – INFORMATION RECEIVER NAME
NM108 ID Code Qualifier
“46” will be returned
48 2100B NM1 - INFORMATION SOURCE NAME
NM109 Identification Code
Information receiver’s primary identifier will be returned
49 2200B TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER
TRN02 Reference Identification
Value submitted in the BHT03 data element from 837 is returned
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-1 Health Care Claim Status Category Code
A1 = Acknowledgement/Receipt- The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-2 Health Care Claim Status Category Code
19 = Entity acknowledges receipt of claim/encounter
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC01-3 Health Care Claim Status Category Code
“41” will be returned to indicate submitter
51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC02 Date Status information effective date will be shown
52 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC03 Action Code “WQ” for Accept which is the default value representing transaction level acceptance. Specific rejections/acceptance will be reported in Loop 2200D. If the entire transaction set is rejected “U” will be returned.
52 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER
STC04 Monetary Amount
Monetary sum of all claims within ST-SE transaction set
55 2200B QTY – TOTAL ACCEPTED QUANTITY
QTY01 Quantity Qualifier
“90” will be returned
55 2200B QTY – TOTAL ACCEPTED QUANTITY
QTY02 Quantity Total accepted quantity
56 2200B QTY – TOTAL REJECTED QUANTITY
QTY01 Quantity Qualifier
“AA” will be returned
56 2200B QTY – TOTAL REJECTED QUANTITY
QTY02 Quantity Total rejected quantity for information receiver (not created if all claims are accepted)
COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT
VERSION 5010
85 2200D REF- PAYER CLAIM CONTROL NUMBER
REF01 Reference Identification Qualifier
“1K” for Payer’s claim number will be returned.
85 2200D REF- PAYER CLAIM CONTROL NUMBER
REF02 Reference Identification
Payer claim control number will be returned.
86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES
REF01 Reference Identification Qualifier
“D9” will be returned when a clearing house tracking number is received in 837
86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES
REF02 Reference Identification
Clearing house tracking number is returned if received in 837
87 2200D REF- INSTITUTIONAL BILL TYPE IDENTIFICATION
REF01 Reference Identification Qualifier
“BLT” will be returned to indicate Institutional Bill Type identifier (Applies to Institutional claims)
87 2200D REF - INSTITUTIONAL BILL TYPE IDENTIFICATION
REF02 Reference Identification
Institutional Type of Bill received on the claim will be returned (Applies to Institutional claims)
87 2200D DTP - CLAIM LEVEL SERVICE DATE
DTP01 Date/Time Qualifier
“472” indicating Service will be returned
89 2200D DTP - CLAIM LEVEL SERVICE DATE
DTP02 Date Time Period Format Qualifier
D8/RD8 depending if the service period is a date or range of dates
89 2200D DTP - CLAIM LEVEL SERVICE DATE
DTO03 Date Time Period
Service date
90 2220D SVC - SERVICE LINE INFORMATION
SVC01 Composite Medical Procedure
This field will be populated with the values received from 837 Professional or 837 Institutional Service Line Information when service line has an error. The following fields will indicate associated errors.
94 2220D STC- SERVICE LINE LEVEL STATUS INFORMATION
STC01-1 Health Care Claim Status Code
See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
95 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC01-2 Health Care Claim Status Code
See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement
96 2220D STC- SERVICE LEVEL STATUS INFORMATION
STC01-3 Health Care Claim Status Code
Entity Code ‘41’ – Submitter will
be returned. See Additional Entity/Status Code in section Rejection Criteria/Error