Transcription
Companion Guide Version Number: V 1.2 – TDC.11.001July 7, 2022
HealthLink 837 Companion GuideThis template is Copyright 2010 by The Workgroup for Electronic Data Interchange (WEDI)and the Data Interchange Standards Association (DISA), on behalf of the Accredited StandardsCommittee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety providedthat this copyright notice is not removed. It may not be sold for profit or used in commercialdocuments without the written permission of the copyright holder. This document is provided “asis” without any express or implied warranty. Note that the copyright on the underlying ASC X12Standards is held by DISA on behalf of ASC X12.2011 Companion Guide copyright by HealthLinkPrefaceCompanion Guides (CG) may contain two types of data, instructions for electronic communications withthe publishing entity (Communications/Connectivity Instructions) and supplemental information forcreating transactions for the publishing entity while ensuring compliance with the associated ASC X12 IG(Transaction Instructions). Either the Communications/Connectivity component or the TransactionInstruction component must be included in every CG. The components may be published as separatedocuments or as a single document.The Communications/Connectivity component is included in the CG when the publishing entity wants toconvey the information needed to commence and maintain communication exchange.The Transaction Instruction component is included in the CG when the publishing entity wants to clarifythe IG instructions for submission of specific electronic transactions. The Transaction Instructioncomponent content is limited by ASCX12’s copyrights and Fair Use statement.July 2022 005010ii
HealthLink 837 Companion GuideTable of ContentsPreface . ii1 Transaction Instruction (TI) Introduction . 11.1 Background . 1Overview of HIPAA Legislation. 1Compliance according to HIPAA . 1Compliance according to ASC X12 . 11.2 Intended Use. 123Included ASC X12 Implementation Guides . 2Instruction Tables . 33.1 005010X222A1 Health Care Claim: Professional . 33.2 005010X223A2 Health Care Claim: Institutional . 134TI Additional Information . 194.1 Business Scenarios. 19Bundling (Code Editing) .194.2 Payer Specific Business Rules and Limitations . 21HealthLink Electronic Transaction Manual.21Applicability .21Scope of Companion Document.21File Naming Conventions .21PGP Encrypted Files: .21Decrypted files: .22Identifying Products (HMO, PPO, Open Access) .22Identifying Participating Providers Status .22Provider Taxonomy (Specialty) Codes .23Identifying A Network (Repricing Organization Identifiers) .23Repricing Messages.23Professional: Claims 837P (CMS1500) Messages .24Professional: Billing Provider (2010AA) .24Professional: Pay-To-Provider (2010AB) .24Professional: Subscriber Name (2010BA) .24Professional: Payor Name (2010 BB) .24Professional: Supervising Provider (2310 E) .25Professional: Billing Provider Communication Number )2010 AA) .25Professional: Provider Signature on file and Assignments.25Professional: Claim Frequency Code (Original and Adjustments) .25Professional: Patient Signature Source Code.25Professional: Related Causes Code .25Professional: Accident Date .25Professional: Admission/Discharge Date .25Professional: Onset of Current Symptom, Illness .25Professional: Referring/Ordering Physician Information .25Professional: Purchased Service Provider Name .26Professional: Other Insurance Information .26Professional: Rendering Provider Code Qualifier and ID .26Institutional: Claims 837I (UB04s) Messages .26Institutional: Subscriber Group Number and Group Name .26July 2022 005010iii
HealthLink 837 Companion GuideInstitutional: Billing Provider (2010 AA) .26Institutional: Pay-to-Provider .26Institutional: Subscriber Name.26Institutional: Related Causes Code .27Institutional: Attending Physician Name (2310 A) .27Institutional: Operating Physician Name (2310 B) .27Institutional: Other Operating Physician Name (2310C) .27Institutional: Other Insurance Coverage Information .27Institutional: Revenue Codes.27Healthlink’s Document Control Number.27Pricing Methodologies .28Coordination of Benefits .28Non-Standard Claims Converted to Standard Claims .294.3 Frequently Asked Questions . 30What is HealthLink’s policy regarding 997s? .30What is HealthLink NPI strategy? .30HealthLink EDI Strategy for NPI .30NPI Background .30What is HealthLink 5010 implementation strategy? .30HealthLink 4010/5010 Implementation Strategy .30Does HealthLink use a compliance Tool? .30Compliance Tool .30What does HealthLink require from Providers for submitting electronic claims? .30Claim Submissions from Providers .30How may Payors receive their electronic claims from HealthLink? .31Claims Submissions to Payors from HealthLink .31How does HealthLink prefer to receive their eligibility from Payor’s? .31Electronic Claims and Eligibility .31Will HealthLink accept PO or Lock Box addresses for a Billing Provider?.31Will HealthLink continue to accept diagnosis Present on Admission (POA) indicators inREF segments that the industry used with HIPAA 4010 claims? .31Which type of claim should Providers use for Anesthesia claims? .314.4 Other Resources . 325010 Technical Reports Type 3.32http://www.wpc-edi.com/ .32Latest Code Lists .325010 and ICD-10 Final Rule .32Appendix A Repricing Organization Identifiers and Descriptions .33Appendix B National Care Networks (NCN) Identifiers and Descriptions .3656TI Change Summary . 39Communication / Connectivity Instructions . 39HealthLink 5010 Support .39EDI Support .39Transmission Methods .39July 2022 005010iv
HealthLink 837 Companion Guide1Transaction Instruction (TI) Introduction1.1 BackgroundOverview of HIPAA LegislationThe Health Insurance Portability and Accountability Act (HIPAA) of 1996 carries provisions foradministrative simplification. This requires the Secretary of the Department of Health and HumanServices (HHS) to adopt standards to support the electronic exchange of administrative andfinancial health care transactions primarily between health care providers and plans. HIPAAdirects the Secretary to adopt standards for transactions to enable health information to beexchanged electronically and to adopt specifications for implementing each standard HIPAAserves to: Create better access to health insurance Limit fraud and abuseReduce administrative costsCompliance according to HIPAAThe HIPAA regulations at 45 CFR 162.915 require that covered entities not enter into atrading partner agreement that would do any of the following: Change the definition, data condition, or use of a data element or segment in astandard. Add any data elements or segments to the maximum defined data set. Use any code or data elements that are marked “not used” in the standard’simplementation specifications or are not in the standard’s implementationspecification(s). Change the meaning or intent of the standard’s implementation specification(s).Compliance according to ASC X12ASC X12 requirements include specific restrictions that prohibit trading partners from: Modifying any defining, explanatory, or clarifying content contained in theimplementation guide. Modifying any requirement contained in the implementation guide.1.2 Intended UseThe Transaction Instruction component of this companion guide must be used inconjunction with an associated ASC X12 Implementation Guide. The instructions in thiscompanion guide are not intended to be stand-alone requirements documents. Thiscompanion guide conforms to all the requirements of any associated ASC X12Implementation Guides and is in conformance with ASC X12’s Fair Use and Copyrightstatements.July 2022 0050101
HealthLink 837 Companion Guide2Included ASC X12 Implementation GuidesThis table lists the X12N Implementation Guides for which specific transactionInstructions apply and which are included in Section 3 of this document.Unique IDName005010X222A1Health Care Claim: Professional (837)005010X223A2Health Care Claim: Institutional (837)July 2022 0050102
HealthLink 837 Companion Guide3Instruction TablesThese tables contain one or more rows for each segment for which a supplementalinstruction is needed.LegendSHADED rows represent “segments” in the X12N implementation guide.NON-SHADED rows represent “data elements” in the X12N implementation guide.3.1Loop005010X222A1 Health Care Claim: onally, we will receive electronicclaims with Billing Provider information, butno Provider name and/or Provider ID forthis, which is required under HIPAA.2010AANM1Billing Provider Name2010AANM101Entity Identifier Code852010AANM102Entity Type Qualifier22010AANM103Billing Provider Last orOrganizational NameXXIf this field is blank, HealthLink willpopulate the data element.2010AANM108Identification CodeQualifierXXIf this field is blank, HealthLink willpopulate the data element.2010AANM109Billing Provider IdentifierLoopReference2010AAPER2010AAPER04NameIf this field is blank, HealthLink willpopulate the data element with“9999999999”.CodesNotes/CommentsBilling Provider ContactInformationPer CMS HIPAA guidance, telephonenumbers should consist only of tennumeric digits. Dashes and parenthesismarks are invalid characters.Communication NumberIf this field has invalid characters,HealthLink will populate the data in thefollowing manner: “0000000000” (tenzeros)2010AAPER06Communication NumberIf this field has invalid characters,HealthLink will populate the data in thefollowing manner: “0000000000” (tenzeros)2010AAPER08Communication NumberIf this field has invalid characters,HealthLink will populate the data in thefollowing manner: “0000000000” (tenzeros)LoopReference2000BSBRJuly 2022 005010NameSubscriber InformationCodesNotes/CommentsSeveral of the payors for which we repriceclaims utilize HealthLink’s Open Accessnetwork products for some of their groups.3
HealthLink 837 Companion Guide2000BSBR09Claim Filing IndicatorCode12The payor may utilize the followingmethod to determine the status of theprovider who rendered the service.2000BSBR09Claim Filing IndicatorCodeHMThe payor may utilize the followingmethod to determine the status of theprovider who rendered the service.2000BSBR09Claim Filing IndicatorCodeZZThe payor may utilize the followingmethod to determine the status of theprovider who rendered the service.2000BSBR09Claim Filing IndicatorCodeWCThe payor may utilize the followingmethod to determine the status of theprovider who rendered the service.2000BSBR09Claim Filing IndicatorCode14The payor may utilize the followingmethod to determine the status of theprovider who rendered the onally, we will receiveelectronic claims with Subscriberinformation, but no Subscriber nameand/or Subscriber ID for this, whichis required under HIPAA.2010BANM1Subscriber Name2010BANM101Entity Identifier CodeIL2010BANM102Entity Type Qualifier12010BANM103Subscriber Last NameXXIf this field is blank, HealthLink willpopulate the data element.2010BANM104Subscriber First NameXXIf this field is blank, HealthLink willpopulate the data element.2010BANM108Identification Code QualifierMIIf this field is blank, HealthLink willpopulate the data element.2010BANM109Subscriber PrimaryIdentifierJuly 2022 005010If this field is blank, HealthLink willpopulate the data element with“9999999999”.4
HealthLink 837 Companion lly, we will receive electronicclaims with Payor information but no Payorname and/or Payor ID for this, which isrequired under HIPAA.2010BBNM1Payer Name2010BBNM101Entity Identifier CodePR2010BBNM102Entity Type Qualifier22010BBNM103Payer Last NameXXIf this field is blank, HealthLink will populatethe data element.2010BBNM104Payer First NameXXIf this field is blank, HealthLink will populatethe data element.2010BBNM108Identification Code QualifierPIIf this field is blank, HealthLink will populatethe data element.2010BBNM109Payer IdentifierLoopReferenceName2300CLMClaim Information2300CLM05-32300If this field is blank, HealthLink will populatethe data element with “9999999999”.CodesNotes/CommentsClaim Frequency Code1If the claim is original to HealthLink, CLM053 in the 2300 loop will be populated with “1”(“Original claim”).CLM05-3Claim Frequency Code7If this is an adjustment to a claim previouslyprocessed by HealthLink, CLM05-3 will bepopulated with “7” (“Replacement claim”).2300CLM06Provider or SupplierSignature IndicatorYIf this field is blank, HealthLink will populatethe data element.2300CLM07Medicare Assignment CodeAIf this field is blank, HealthLink will populatethe data element.2300CLM10Patient Signature SourceCodePIf CLM09 (Release of Information Code)does not equal “N”, this code is required. IfCLM10 is blank, HealthLink will populate thedata in the following mannerLoopReferenceNameCodesNotes/CommentsIf an Accident Date is provided on the claimthe assumption is that the condition beingreported is Accident or Employment related.In these cases a Related-Causes Code isrequired in the 837.2300CLM11Related Causes Information2300CLM11-1Related Causes CodeOAIf this field is blank, HealthLink will populatethe data element.LoopReferenceNameCodesNotes/CommentsJuly 2022 0050105
HealthLink 837 Companion GuideIf an Accident indicator is provided on theclaim the assumption is that the conditionbeing reported is Accident or Employmentrelated. In these cases an Accident Date isrequired in the 837.2300DTPDate - Accident2300DTP01Date Time Qualifier4392300DTP02Date Time Period FormatQualifierD82300DTP03Accident DateLoopReferenceName2300DTPDate - Admission2300DTP01Date Time Qualifier4352300DTP02Date Time Period FormatQualifierD82300DTP03Related HospitalizationAdmission DateLoopReferenceName2300DTPDate - Discharge2300DTP01Date Time Qualifier962300DTP02Date Time Period FormatQualifierD82300DTP03Related HospitalizationDischarge DateLoopReferenceName2300DTPDate - Onset Of CurrentIllness/Symptom2300DTP01Date Time Qualifier4312300DTP02Date Time Period FormatQualifierD82300DTP03Onset of Current Illness orInjury DateLoopReferenceNameJuly 2022 005010If this date is blank or invalid, HealthLink willpopulate the following data element with"19010101"CodesNotes/CommentsIf a discharge date is present on the claim,the admission date is required.If this date is blank or invalid, HealthLink willpopulate the following data element with"19010101"CodesNotes/CommentsIf an admission date is present on the claim,the discharge date is required.If this date is blank or invalid, HealthLink willpopulate the following data element with"19010101"CodesNotes/CommentsIf the claim indicates there was a relatedillness or symptoms but does not have avalid date. HealthLink will populate with adefault value.If this date is blank or invalid, HealthLink willpopulate the following data element with"19010101"CodesNotes/Comments6
HealthLink 837 Companion Guide2300REFRepriced Claim Number2300REF01Reference IdentificationQualifier2300REF02Repriced Claim ReferenceNumberLoopReferenceName2300REFAdjusted Repriced ClaimNumber2300REF01Reference IdentificationQualifier2300REF02Adjusted Repriced ClaimReference NumberLoopReferenceName2300REFClaim Identifier ForTransmissionIntermediaries2300REF01Reference IdentificationQualifier2300REF02Clearinghouse TraceNumberLoopReferenceName2300HCPHealthLink assigns a unique DocumentControl Number (“DCN”) (11 digits) to eachclaim that it processes.9AThe DCN assigned to the claim has astructure which uses the DCN“E1804021010” as an example: See section4.2.3.9CodesNotes/Comments9CThe DCN assigned to the claim has astructure which uses the DCN“E1804021010” as an example: See section4.2.3.9CodesNotes/CommentsD9Clearinghouse Trace NumberThe DCN assigned to the claim has astructure which uses the DCN“E1804021010” as an example: See section4.2.3.9CodesNotes/CommentsClaim Pricing/RepricingInformationThe provider participating status can beobtained in the “Line Pricing/RepricingInformation” segment (“HCP”). If a claim hasbeen processed as non-participating, thefollowing elements will be populated:2300HCP01Pricing Methodology0The presence of this value indicates thatthis claim is from a non-participatingprovider.Claims for non-participating providers usingUCR pricing do not use “00”.2300HCP13Reject Reason CodeT1Cannot identify Provider as TPO (ThirdParty Organization) Participant)2300HCP15Exception Code3Services or Specialist not in NetworkJuly 2022 0050107
HealthLink 837 Companion lly, we will receive claims withReferring Physician information but noProvider name and/or Provider ID for thisphysician, which is required under HIPAA.2310ANM1Referring Provider Name2310ANM101Entity Identifier CodeDN2310ANM102Entity Type Qualifier12310ANM103Referring Provider LastNameXXIf this field is blank, HealthLink will populatethe data element.2310ANM104Referring Provider FirstNameXXIf this field is blank, HealthLink will populatethe data element.2310ANM108Identification Code QualifierXXIf this field is blank, HealthLink will populatethe data element.2310ANM109Referring Provider IdentifierLoopReferenceName2310BNM1Rendering Provider Name2310BNM108Identification Code Qualifier2310BNM109Rendering ProviderIdentifierLoopReferenceNameIf this field is blank, HealthLink will populatethe data element with “9999999999”.CodesNotes/CommentsOccasionally, we will receive electronicclaims with “Rendering Provider” informationbut no Provider ID Number for thisphysician, which is required under HIPAA.XXIf this field is blank, HealthLink will populatethe data element.If this field is blank, HealthLink will populatethe data element with “9999999999”.CodesNotes/CommentsOccasionally, we will receive electronicclaims with Supervising Provider informationbut no Provider name and/or Provider ID forthis physician, which is required underHIPAA.2310DNM1Supervising Provider Name2310DNM101Entity Identifier CodeDQ2310DNM102Entity Type Qualifier12310DNM103Supervising Provider LastNameXXIf this field is blank, HealthLink will populatethe data element.2310DNM104Supervising Provider FirstNameXXIf this field is blank, HealthLink will populatethe data element.2310DNM109Supervising ProviderIdentifierJuly 2022 005010If this field is blank, HealthLink will populatethe data element with “9999999999”.8
HealthLink 837 Companion her SubscriberInformation2320SBR01Payer ResponsibilitySequence Number CodeS2320SBR02Individual RelationshipCode212320SBR03Insured Group or PolicyNumberIf this field is blank, HealthLink will populatethe data element with “”UNKNOWN.2320SBR04Other Insured Group NameIf this field is blank, HealthLink will populatethe data element with “”UNKNOWN.2320SBR09Claim Filing Indicator CodeZZLoopReferenceNameCodes2320OIOther Insurance CoverageInformation2320OI03Benefits AssignmentCertification IndicatorYIf this field is blank, HealthLink will populatethe data element.LoopReferenceNameCodesNotes/CommentsIf the claim contains other insuranceinformation or indicates there is othercoverage, then additional other insurancecoverage information is required.Notes/CommentsIf the claim contains other insuranceinformation or indicates there is othercoverage, then additional other insurancecoverage information is required.If the claim contains other insuranceinformation or indicates there is othercoverage, then additional other insurancecoverage information is required.2330ANM12330ANM101Entity Identifier CodeIL2330ANM102Entity Type Qualifier12330ANM103Other Insured Last NameXXIf this field is blank, HealthLink will populatethe data element.2330ANM104Other Insured First NameXXIf this field is blank, HealthLink will populatethe data element.2330ANM109Other Insured IdentifierJuly 2022 005010Other Subscriber NameIf this field is blank, HealthLink will populatethe data element with “9999999999”.9
HealthLink 837 Companion GuideLoopReferenceNameCodesNotes/CommentsIf the claim contains other insuranceinformation or indicates there is othercoverage, then additional other insurancecoverage information is required.2330BNM1Other Payer Name2330BNM101Entity Identifier CodePR2330BNM102Entity Type Qualifier22330BNM103Other Payer Last orOrganization NameXXIf this field is blank, HealthLink will populatethe data element.2330BNM108Identification Code QualifierPIIf this field is blank, HealthLink will populatethe data element.2330BNM109Other Payer If this field is blank, HealthLink will populatethe data element with “9999999999”.CodesOccasionally, we will receive electronicclaims without the required Units of Servicefield, which is required under HIPAA.Professional ServiceService Unit CountLoopReferenceName2400HCPLine Pricing/RepricingInformationNotes/Comments1If this field is blank, HealthLink will populatethe data element.CodesNotes/Comments2400HCP01Pricing Methodology0The presence of this value indicates thatthis claim is from a non-participatingprovider.Claims for non-participating providers usingUCR pricing do not use “00”.2400HCP13Reject Reason CodeT1“T1” (Cannot identify Provider as TPO (ThirdParty Organization) Participant)2400HCP15Exception Code3“3” (Services or Specialist not in Network)July 2022 00501010
HealthLink 837 Companion lly, we will receive electronicclaims with “Rendering Provider” informationbut no Provider ID Number for thisphysician, which is required under HIPAA.2420ANM1Rendering Provider Name2420ANM108Identification Code Qualifier2420ANM109Rendering ed Service ProviderName2420BNM101Entity Identifier CodeQB2420BNM102Entity Type Qualifier12420BNM108Identification Code QualifierXX2420BNM109Other Payer PrimaryIdentifierLoopReferenceNameXXIf this field is blank, HealthLink will populatethe data element.If this field is blank, HealthLink will populatethe data element with “9999999999”.CodesNotes/CommentsOccasionally, we will receive claims withPurchased Service Provider information butno Provider name and/or Provider ID for thisphysician, which is required under HIPAA.If this field is blank, HealthLink will populatethe data element.If this field is blank, HealthLink will populatethe data element with “9999999999”.CodesNotes/CommentsOccasionally, we will receive claims withOrdering Physician information but noProvider name and/or Provider ID for thisphysician, which is required under HIPAA.2420ENM1Ordering Provider Name2420ENM101Entity Identifier CodeDK2420ENM102Entity Type Qualifier12420ENM103Ordering Provider LastNameXXIf this field is blank, HealthLink will populatethe data element.2420ENM104Ordering Provider FirstNameXXIf this field is blank, HealthLink will populatethe data element.2420ENM108Identification Code QualifierXXIf this field is blank, HealthLink will populatethe data element.2420ENM109Ordering Provider IdentifierJuly 2022 005010If this field is blank, HealthLink will populatethe data element with “9999999999”.11
HealthLink 837 Companion lly, we will receive claims withReferring Physician information but noProvider name and/or Provider ID for thisphysician, which is required under HIPAA.2420FNM12420FNM101Entity Identifier CodeDN2420FNM102Entity Type Qualifier12420FNM103Referring Provider LastNameXXIf this field is blank, HealthLink will populatethe data element.2420FNM104Re
HIPAA directs the Secretary to adopt standards for transactions to enable health information to be exchanged electronically and to adopt specifications for implementing each standard HIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs Compliance according to HIPAA
