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835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments835 Health Care ClaimPayment/AdviceCompanion GuideForDeltaCare FacilityCapitation and TotalCompensation PaymentsRefers to ASC X12 835 Technical Report Type 3 GuideHIPAA/V5010X221A1Version: 2.4Publication: June 30, 2022Author: Delta DentalJune 30, 2022 005010X221A1/8351
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsDisclosure StatementThis document is Copyright 2016 by Delta Dental of California. All rights reserved. It may be freely redistributedin its entirety provided that this copyright notice is not removed. It may not be sold for profit or used incommercial documents without the written permission of the copyright holder. This document is provided “as is”without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held byDISA on behalf of ASC X12.PrefaceThis Companion Guide to the ASC X12N Implementation Guides and associated errata adopted under HIPAAclarifies and specifies the data content when exchanging electronically with Delta Dental of California.Transmissions based on this companion guide, used in tandem with the X12N Technical Report Type 3 Guides arecompliant with both X12 syntax and those guides. This Companion Guide is intended to convey information that iswithin the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The CompanionGuide is not intended to convey information that in any way exceeds the requirements or usages of data expressedin the Implementation Technical Report Type 3 Guides.June 30, 2022 005010X221A1/8352
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsTable of Contents1 Introduction . 51.1 Scope. 51.2 Overview . 51.3 References. 52 Getting Started . 72.1 Working with Delta Dental of California . 72.2 Trading Partner Registration . 72.3 Trading Partner Enrollment/Onboarding . 73 Notes to the Trading Partners. 83.13.23.33.43.53.63.73.8Business Use and Purpose . 8Claims Types . Error! Bookmark not defined.Data Sources . 8Generation Frequency. 8Data Content/Structure. 8Validation/Balancing . 8Delimeters . 8Other . 94 Testing with the Payer . 94.14.24.34.4Testing Requirements . 9Provider 835 Request Enrollment File . 10Provider 835 Request Header Record Layout . 11Provider 835 Request Detail Record Layout. 125 Connectivity with the Payer / Communications . 145.1 Transmission Administrative Procedures . 145.1.1 Re-transmission procedures .145.2 Communication Protocols Specifications . 145.3 Passwords . 146 Contact information . 156.1 EDI Customer Service . 156.2 Provider Service Number . 156.3 Applicable websites / e-mail . 15June 30, 2022 005010X221A1/8353
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments7 Control Segments / Envelopes . 167.1 ISA Interchange Control Header . 167.2 GS Functional Group Header . 167.3 ST Transaction Set Header . 177.4 BPR Financial Information . 187.5 TRN Reassociation Trace Number . 207.6 REF Receiver Identification . 207.7 N1 Payer Identification . 207.8 PER Payer WEB Site . 217.9 N1 Payee Identification . 217.10N3 Payee Address . 227.11N4 Payee City, State, Zip Code. 227.12REF Payee Additional Identification . 228 Acknowledgements . 248.1 999 Functional Acknowledgment . 248.2 TA1 Interchange Acknowledgment . 24Document Revision History . 25June 30, 2022 005010X221A1/8354
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments1 IntroductionUnder the Administrative Simplification provisions of the Health InsurancePortability and Accountability Act (HIPAA) of 1996, the Secretary of theDepartment of Health and Human Services (HHS) is directed to adopt standards tosupport the electronic exchange of administrative and financial health caretransactions. The purpose of the Administrative Simplification portion of HIPAA isenable health information to be exchanged electronically and to adopt standardsfor those transactions.1.1 ScopeThis companion guide is intended for all Trading Partners interested in exchangingHIPAA compliant X12 transactions with any of Enterprise Delta Dental Payers. It isintended to be used in conjunction with X12N Implementation Guides and is notintended to contradict or exceed X12 standards. It contains information aboutspecific Delta Dental of California requirements for processing following X12NImplementation Guides:Health Care Claim Payment/Advice 835 Implementation Guide ASC X12Standards for Electronic Data Interchange Technical Report Type 3 (TR3),version 005010X221A1All instructions in this document are written using information known at the time ofpublication and are subject to change.1.2 OverviewThe purpose of this document is to introduce and provide information about DeltaDental’s Enterprise solution for receiving 835 transactions. This document covershow Delta Dental will work with Trading Partners on testing, connectivity, contactinformation, control segments/envelopes, payer specific business rules andlimitations, acknowledgements, and trading partner agreements.1.3 ReferencesJune 30, 2022 005010X221A1/8355
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsThe ASC X12N 835 (version 005010X221A1) Technical Report Type 3 guide forHealth Care Claim Payment/Advice (835) has been established as the standard forpayments transactions and is available inal-guidesDelta Dental of California’s documentation on transactions for Trading Partners islocated ort.htmlJune 30, 2022 005010X221A1/8356
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments2 Getting Started2.1 Working with Delta Dental of CaliforniaEntities interested in receiving 835/Electronic Remittance Advice (ERA) via theDelta Dental enterprise solution should email or call the Delta Dental EDI contactrelated to Trading Partner Relations.2.2 Trading Partner RegistrationNew entities must submit in writing or email a request to become a Trading Partnerto the Delta Dental of California EDI contact related to Trading Partner Relations.Delta Dental reserves the right to have new Trading Partners use existing TradingPartner connections. In the request, submitter must include the followinginformation:Contact NameCompany NameAddress, City, State and ZipE-Mail address of contactTelephone of contactNumber of Delta Enterprise Provider Clients Served2.3 Trading Partner Enrollment/OnboardingAll Trading Partners, Clearinghouses, and Providers groups will be provided withapplicable agreement during enrollment/onboarding period.June 30, 2022 005010X221A1/8357
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments3 Notes to the Trading Partners3.1 Business Use and PurposeThis document provides a statement of the 835 utilization requirements unique toDelta Dental processing. Clearinghouses and Trading Partners must use this guidein conjunction with the 835 Health Care Claim Payment/Advice TransactionImplementation Guide (TR3).3.2 Data SourcesRemittance Advices returned in the 835 will apply only to Capitation and TotalCompensation Payments for DeltaCare Facility. No claims or encounter paymentdetails will be provided.3.3 Generation Frequency1. Delta Dental's system produces Capitation and Total Compensation Paymentstransactions based on the DeltaCare Payment Processing (PP) cyclesschedules.2. The Capitation and Total Compensation Payments transactions are batched atthe end of the day into an 835 EDI files. The 835 EDI files are batched based onspecific Trading Partner/Delta Dental Payers. If a system limitation or agreedtransmission size limitation is met, multiple 835 EDI files may be generated foreach TP/Payers.3. Batching of X12 835 transactions occurs once a day after each Capitation TotalCompensation Payment Processing (PP) cycles.3.4 Data Content/Structure1. An 835 transaction will have one Interchange Group (ISA/IEA), one FunctionalGroup (GS/GE), and may have one or more Transaction Sets (ST/SE).2. A Transaction Set (ST/SE) will contain either an individual Capitation or TotalCompensation Payments for an Individual Remittance Advice.3. A Remittance Advice will be associated with a Capitation or Total Compensationpayment details.3.5 DelimetersSegment Separator (tilde)Data Element Separator * (asterisk)Sub-element Separator : (colon)Repetition Separator (caret)June 30, 2022 005010X221A1/8358
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments3.6 Other1. Codes not utilized by Delta Dental are excluded from this guide.2. Supplemental notes (Delta Dental's Note for the Trading Partner), if applicable,are added at the segment or data element level.4 Testing with the Payer4.1 Testing RequirementsTrading Partner will use the following steps to test with any of Enterprise DeltaDental Payers.Step 1: Trading Partner RegistrationTrading Partner should contact Delta Dental of California to complete and submitthe Trading Partner Agreement Form for registration process.Step 2: Trading Partner AuthenticationDelta Dental will verify the information on the Trading Partner Agreement Formand will approve the Submitter ID requests.Step 3: Trading Partner Validation/TestingTesting environment will be setup between Trading Partners and Delta Dental toallow for end-to-end system integration and Trading Partner Validation (TPV).Trading Partner will receive 835/ERAs test transactions and verify that all systemsinvolved can properly receive and process X12 compliant transactions. The UsageIndicator (ISA15) on 835/ERA’s must be “T”.Step 4: Trading Partner ImplementationOnce Trading Partner Validation (TPV) and end-to-end system integration testingis complete, a Trading Partner will be migrated to Production environment and canbegin to receive and process 835/ERA transactions. The Usage Indicator (ISA15)on 835/ERA’s must be “P”.June 30, 2022 005010X221A1/8359
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments4.2 Provider 835 Request Enrollment FileOnce Provider Groups/Providers are enrolled to receive 835/ERA for Fee-forService claims, if the same Provider Groups/Providers are also contracted asDeltaCare Facility to submit DeltaCare claims and encounters, the applicable835/ERA for Capitation and Total Compensation Payments will be automaticallygenerated and sent after each Capitation and Total Compensation Paymentscycles regardless of the submission sources.No need for a separate enrollment process for DeltaCare Facility to receive835/ERA for Capitation and Total Compensation Payments.4.3 Provider 835 Request Enrollment File NotificationsDelta Dental will perform a series of file level validations on each 835 providerenrollment file based on the specifications outlined in section 4.4 and 4.5 of thisdocument. If a provider enrollment file fails any of the validation at either theheader level or the detail level the corresponding trading partner/sender willreceive a file processing failure notification via email with the below mentionedinformation and none of the provider records from the file will be enrolled for the835 ERA until the file is corrected and resubmitted.Notification Method – EmailSender – noreply-Prod-Moveit@delta.orgSubject – Provider 835 Enrollment File Processing Failure On ‘DateMM/DD/YYYY’Body – File ‘provider 835 enrollment file name’ has failed file formatvalidations and will not be processed further by Delta Dental. Please correctand resubmit the file to ensure enrollment of the corresponding providers forthe 835 ERA process. For further inquiries or questions please reach out todeltadentalproduction@delta.org.Thank you,Delta DentalJune 30, 2022 005010X221A1/83510
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments4.4 Provider 835 Request Header Record LayoutField NameDescriptionLengthStartPositionTechnical SpecificationRecord TypePR0 identifiers Header31Must contain a value or PR0.This is Uppercase PR followed bythe number zero.File IDIdentifies that this is a file ofProvider ID's that haverequested electronicremittanceTotal Number of PR1Provider 835 RequestRecords Sent on FileIdentifies Trading Partner.94Must contain a value ofP835REQST.All letters must be uppercase.913Numeric Left Pad with Zeros1522Alphanumeric - case sensitiveRight Pad with Spaces :Record CountTrading Partner NameValid Values are:EMDEONEHGTESIAQSISecureEDITrading PartnerReceiver IDIdentifies Trading Partner.837Alphanumeric - case sensitive:for EMDEON value is 'DDNEIC00'for EHG value is 'DDSRIX00'for TESIA value is 'DDTESX00'for QSI value is 'DDQSIX00'for SecureEDI value is 'DDSEDI00'Create DateApplication RecieverCodeDate File was createdValue to be populated on835's8154553CCYYMMDD - must be valid dateValue to be determinied by TradingPartner13368SpacesFillerJune 30, 2022 005010X221A1/83511
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments4.5 Provider 835 Request Detail Record LayoutField NameDescriptionLengthStartPositionTechnical SpecificationRecord TypePR1 Identifiers ProviderRequest Detail Record31 PR1Provider Group Tax IDNumberTIN of Provider GroupRequesting electronic 83594 Alphanumeric - Right Pad withSpacesProvider Group NameName of Group Provider3013 Alphanumeric - Right Pad withSpacesProvider Group NPINPI for the Group Provider.This is the Type 2 NPI.3043 Alphanumeric - Right Pad withSpacesProvider Group 835Dual DeliveryRequestedIndicates whether or not835 Dual Delivery isrequested or waived. DualDelivery refers to the 835start-up period where theprovider will receive bothpaper and electronic 835's173 AlphanumericY Provider Group wants 835dual Delivery. They will receiveboth paper and electronic 835's forthe number of days specified inProvider Group Dual DeliveryDays.N Provider Group waives 835dual delivery period. This ProviderGroup wants to only receiveelectronic 835's once they aresetup up.NOTE: If this field is left blank orcontains any value other than 'N' or'Y', the default value of 'Y' will beused.June 30, 2022 005010X221A1/83512
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsProvider Group DualDelivery Days274 Alphanumeric - Right Pad withSpacesThis is the number of days (1 - 99)during which a provider groupwill receive both paper andelectronic 835's.Note:This field is ignored when DualDelivery Requested is 'N'.When the Dual Delivery Requested is'Y' and this field is "0" ornon numeric, the default of 31 dayswill be used.Keep in mind that Delta Dental onlypays claims weekly so if the days is setlow it is possible that the DualDelivery Period will end before any835's are generated.FillerJune 30, 2022 005010X221A1/83512576 Spaces13
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments5 Connectivity with the Payer / Communications5.1 Transmission Administrative ProceduresTrading Partner must use Delta Dental’s designated secured FTP drop zone https://ftp.delta.org/ to login and retrieve 835 X12 files. Trading Partner using thedesignated FTP drop zone must use authorized User ID and Password to loginand retrieve 835 X12 files.5.1.1 Re-transmission proceduresTrading Partners must send a request to Delta Dental’s EDI Contact for anymissing 835 X12 files for re-transmission.5.2 Communication Protocols SpecificationsThe Delta Dental enterprise solution for 835 transactions supports transactionsformatted according to the ASC X12 Standards for Electronic Data InterchangeTechnical Report Type 3 (TR3).5.3 PasswordsDelta Dental of California security policies requires Trading Partners to useauthorized User ID and Password to login via the designated secured FTP sitehttps://ftp.delta.org/.June 30, 2022 005010X221A1/83514
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments6 Contact information6.1 EDI Customer ServiceTrading Partner Relations Manager: Sharon RossettiPhone Number: 415-995-8829 (x8829)Email Address: SRossetti@delta.orgOperation Hours:Monday through Friday between 8:00 a.m. and 5:00 p.m., Pacific Standard TimeExcluding the following major holidays:New Year’s Day (1/1)Martin Luther King’s Day (3rd Monday in January)President’s Day (3rd Monday in February)Memorial Day (Last Monday in May)Independence Day (7/4)Labor Day (1st Monday in September)Thanksgiving Day (4th Thursday in November)Day after Thanksgiving Day (4th Friday in November)Christmas Eve (12/24)Christmas Day (12/25)6.2 Provider Service NumberIf you have questions regarding information related to subscribers that are nontechnical, contact center information can be found at the act/6.3 Applicable websites / .htmlJune 30, 2022 005010X221A1/83515
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments7 Control Segments / Envelopes7.1 ISA Interchange Control HeaderDelta Dental's Notes for the Trading Partner:The Table describes the value specifically required by Delta Dental 835transaction within the ISA Header. The Delta Dental 835 transaction does notexpect any custom values for the IEA segment. Please follow the rules asspecified by the TR3.Segment /Element IDData Element NameCodesDelta Dental A09ISA10ISA11Authorization InformationQualifierAuthorized InformationSecurity Information QualifierInterchange ID QualifierSecurity InformationInterchange Sender IDInterchange ID Qualifier0010 Blank Spaces00ZZ10 Blank Spaces942411167ZZAs specified for each TradingPartnerISA12ISA13Interchange Receiver IDInterchange DateInterchange TimeRepetition SeparatorInterchange Control VersionNumberInterchange Control Number00501000000001ISA14Acknowledgment Requested0ISA15Interchange Usage IndicatorComponent ElementSeparatorT/PISA16YYMMDDHHMM Starts with 0000000010 – No ACK (TA1 or 999)Requested;1 - No ACK (TA1 or 999) RequestedT –Test Data;P –Production Data:7.2 GS Functional Group HeaderDelta Dental's Notes for the Trading Partner:June 30, 2022 005010X221A1/83516
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsThe table below describes Delta Dental of California’s use of the functional groupcontrol segments. It includes a description of expected application sender andreceiver codes. Also included in this section is a description concerning how DeltaDental of California expects functional groups to be sent and how Delta Dental ofCalifornia will send functional groups. These discussions will describe how similartransaction sets will be packaged and Delta Dental of California’s use of functionalgroup control numbers. The Delta Dental 835 transaction does not expect anycustom values for the GE segment. Please follow the rules as specified by the TR3for the GE segment.Segment /Element IDGSGS01GS02GS03GS04GS05GS06GS07GS08Data Element NameCodesFunctional Identifier CodeApplication Sender's CodeDelta Dental NotesHP942411167As specified for eachTrading PartnerApplication Receiver's CodeDateTimeGroup Control NumberResponsible Agency CodeVersion / Release / Industry IdentifierCodeYYYYMMDDHHMM1X005010X221A17.3 ST Transaction Set HeaderDelta Dental's Notes for the Trading Partner:The Delta Dental 835 does not expect any custom values for the ST segments.Please follow the rules as specified by the TR3.Segment /Element IDSTST01ST02Data Element NameCodesTransaction Set Identifier CodeTransaction Set Control Number835June 30, 2022 005010X221A1/835Delta Dental NotesStarts with 0001 or 00000000117
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments7.4 BPR Financial InformationDelta Dental's Notes for the Trading Partner:BPR05 through BPR10 and BPR12 through BPR15 are sent when BPR04 is“ACH”.Segment /Element IDData Element NameCodesDelta Dental NotesBPRBPR01Transaction HandlingCodeBPR02Monetary AmountBPR03Credit/Debit Flag CodeH - Notification Only;I - Remittance InformationOnlyC - CreditTotal ActualProvider PaymentAmount includingInterestAs specified for eachTrading PartnerACH - Automated ClearingHouse (ACH);CHK – Check;BPR04Payment Method CodeBPR05Payment Format CodeBPR06(DFI) ID Number QualifierNON - Non-Payment DataCCP- CashConcentration/Disbursementplus Addenda (CCD ) (ACH)01 - ABA Transit RoutingNumber Including CheckDigits (9 digits);04 - Canadian Bank Branchand Institution NumberExternal Code ListName: 91Description: CanadianFinancial Institution Branchand Institution NumberExternal Code ListName: 60Description: (DFI)Identification NumberBPR07(DFI) IdentificationNumberJune 30, 2022 005010X221A1/835External Code ListName: 418
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsBPR08BPR09BPR10Account Number QualifierAccount NumberOriginating CompanyIdentifierBPR11Originating CompanySupplementalDescription: ABA RoutingNumberDA - Demand DepositPayer Tax IDprefixed with "1Payer ID from DeltaDental's system,may or may not beidentical to thePayer ID fromsubmitted claim.01 - ABA Transit RoutingNumber Including CheckDigits (9 digits);BPR12(DFI) ID Number Qualifier04 - Canadian Bank Branchand Institution NumberExternal Code ListName: 91Description: CanadianFinancial Institution Branchand Institution NumberExternal Code ListName: 60Description: (DFI)Identification NumberBPR13(DFI) IdentificationNumberBPR14BPR15Account Number QualifierAccount NumberExternal Code ListName: 4Description: ABA RoutingNumberDA- Demand Deposit;SG – SavingsPossible values:Check Issue Date(when BPR04 valueis "CHK")EFT Effective Date(when BPR04 valueis "ACH")BPR16DateJune 30, 2022 005010X221A1/83519
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsClaim Receipt Date(when BPR04 valueis "NON")7.5 TRN Reassociation Trace NumberSegment /Element IDData Element NameCodesDelta Dental NotesTRNTRN01TRN02TRN03Trace Type CodeReference IdentificationOriginating CompanyIdentifierTRN04Reference Identification1 - Current Transaction TraceNumbersPayer Tax ID prefixed with"1"Payer ID from Delta Dental'ssystem, may or may not beidentical to the Payer IDfrom submitted claim.7.6 REF Receiver IdentificationSegment /Element IDData Element NameCodesDelta Dental NotesREFREF01REF02Reference IdentificationQualifierEV - Receiver IdentificationNumberDelta Dental's Notes for theTrading Partner: TradingPartner IDReference Identification7.7 N1 Payer IdentificationLoopIDSegment /Element ID1000AN1N101Data Element NameEntity Identifier CodeN102NameN103N104Identification CodeQualifierIdentification CodeJune 30, 2022 005010X221A1/835CodesDelta Dental NotesPR – PayerPlease refer to Delta DentalEnterprise Programs andcorresponding Payer IDbelow.XV - Centers for Medicareand Medicaid Services PlanIDExternal Code List20
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsName: 540Description: Centers forMedicare and MedicaidServices Plan IDDelta Dental ProgramPayer IDDelta Dental of CaliforniaDelta Dental of DelawareDelta Dental of West VirginiaDelta Dental of District of ColumbiaDelta Dental of PennsylvaniaDelta Dental of New YorkDelta Dental Insurance Company (AL, FL, GA, LA, MS, MT, NV, UT, TX)American Association of Retired Personnel (AARP)Community Partnership Program – California (CPP-CA)Texas Cook’s ChildrenDelta Dental of Puerto PPCC6604367697.8 PER Payer WEB SiteDelta Dental's Notes for the Trading Partner:When the REF/Healthcare Policy Identifier segment is required, the corresponding1000A/Payer Identification loop, PER/Payer Web Site also needs to be included inthe 5010 835/Remittance Advice Transaction.LoopIDSegment /Element ID1000APERPER01PER03PER04Data Element NameContact Function CodeCommunication NumberQualifierCommunication NumberCodesIC - Information ContactUR Uniform ResourceLocator (URL)Delta Dental NotesURL will be provided once itbecomes available7.9 N1 Payee IdentificationLoopIDSegment /Element ID1000BN1N101Data Element NameEntity Identifier CodeJune 30, 2022 005010X221A1/835CodesDelta Dental NotesPE - Payee21
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation PaymentsPossible Values:Organization NameN102Individual Name (format isLast Name, First Name,Middle Name)NameFI - Federal Taxpayer'sIdentification Number;N103N104Identification CodeQualifierXX - Centers for Medicareand Medicaid ServicesNational Provider IdentifierExternal Code ListName: 537Description: Centers forMedicare and MedicaidServices National ProviderIdentifierPossible values:NPI from Delta Dental'ssystem that is associated tothe providers on thepayment/claim. May or maynot be identical to the NPIfrom submitted claimExternal Code ListName: 540Description: Centers forMedicare and MedicaidServices Plan IDTax ID, when there is no NPIin Delta Dental's system thatis associated to theProviders on thepayment/claim.Identification Code7.10 N3 Payee AddressDelta Dental's Notes for the Trading Partner:Payee address from Delta Dental's system is sent.7.11 N4 Payee City, State, Zip CodeDelta Dental's Notes for the Trading Partner:Payee address from Delta Dental's system is sent.7.12 REF Payee Additional IdentificationDelta Dental's Notes for the Trading Partner:This segment is generated when the NPI identifier (XX) is sent
835 - Companion Guide for DeltaCare Facility Capitation and Total Compensation Payments January 26, 2017 005010X221A1/835 9 3.6 Other 1. Codes not utilized by Delta Dental are excluded from this guide. 2. Supplemental notes (Delta Dental's Note for the Trading Partner), if applicable, are added at the segment or data element level.
