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Provider EDIReference GuideHighmark EDI OperationsApril 5, 2010 Highmark is a registered mark of Highmark Inc.
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Table of ContentsChapter 1 Introduction131.1 Supported EDI Transactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.2 Real-Time Transaction Capability. . . . . . . . . . . . . . . . . . . . . . . . . 151.2.1 Real-Time Technical Connectivity Specifications. . . . . . . . . 151.2.2 Real-Time Claim Adjudication and Estimation . . . . . . . . . . . 161.2.2.1 General Requirements and Best Practices . . . . . . . . . . . . . 16Chapter 2 General Information192 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192.1 System Operating Hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.2 Provider Data Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.3 Audit Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202.4 Valid Characters in Text Data (AN, string data element type) . . . 21Chapter 3 Security Features233.1 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233.2 Authorized Release of Information . . . . . . . . . . . . . . . . . . . . . . . . 23Chapter 4 Authorization Process254.1 Where to Get Enrollment Forms to Request a Trading Partner ID 254.2 Receiving 835 Transactions Generated from the Payment Cycle(Batch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 264.3 Adding a New Provider to an Existing Trading Partner. . . . . . . . . 264.4 Deleting Providers from an Existing Trading Partner . . . . . . . . . . 264.5 Reporting Changes in Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26April 5, 20103
HighmarkProvider EDI Reference GuideTable of Contents4.6 Out of State Providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Chapter 5 Testing Policy295.1 Web Based . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295.2 Highmark Transactional Testing . . . . . . . . . . . . . . . . . . . . . . . . . . 305.2.1 Real-Time 837 Claim Estimation Demonstration Process . . 30Chapter 6 Communications336.1 Dial-Up / Asynchronous File Transfer . . . . . . . . . . . . . . . . . . . . . . 336.1.1 Dial-Up Command Prompt Option . . . . . . . . . . . . . . . . . . . . 336.2 Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346.2.1 Internet File Transfer Protocol (FTP) through “eDelivery” . . 346.2.2 Internet/Real-Time (HTTPS- Hypertext Terminal Protocol Secure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Chapter 7 Transmission Envelopes397.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397.1.1 Delimiters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397.2 Data Detail and Explanation of Incoming ISA to Highmark. . . . . . 42ISA Interchange Control Header (Incoming). . . . . . . . . . . . . . . . . .427.3 Data Detail and Explanation of Outgoing ISA from Highmark . . . 43ISA Interchange Control Header (Outgoing). . . . . . . . . . . . . . . . . .437.4 Outgoing Interchange Acknowledgment TA1 Segment . . . . . . . . 447.5 Outgoing Functional Acknowledgment 997 Transaction. . . . . . . . 45Chapter 8 Professional Claim (837P)478.1 General Information and Guidelines for Submitting an 837P . . . . 518.1.1 Patient with Coverage from Another Blue Cross Blue ShieldPlan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518.1.1.1 KHP Central Out-of-Area Claims . . . . . . . . . . . . . . . . . . . . . 518.1.1.2 First Priority Life Insurance Company (FPLIC) Out-of-AreaClaims. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 528.1.1.3 Independence Administrators Out-of-Area Claims . . . . . . 524April 5, 2010
HighmarkProvider EDI Reference GuideTable of Contents8.1.1.4 Keystone Health Plan East (KHP East) Out-of-Area Claims 528.1.2 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538.1.3 Data that is Not Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 538.1.4 Transaction Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 548.1.5 Suffix on Highmark’s NAIC Code for Vision Claims . . . . . . . 548.1.6 Ambulance Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 558.1.7 Provider and Service Facility Location Identification Numbers.558.1.8 Claim Submission Acknowledgment . . . . . . . . . . . . . . . . . . 558.1.9 National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . . . . . 568.1.10 Balancing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 588.1.11 Real-Time Claim Adjudication and Estimation . . . . . . . . . . 588.1.11.1 Real-Time 837 Submission Limitations . . . . . . . . . . . . . . . 598.1.11.2 General Requirements and Best Practices . . . . . . . . . . . . 598.2 Data Detail for 837P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60GS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Transmission Type Identification . . . . . . . . . . . . . . . . . . . . . .NM1 Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PRV Billing/Pay-to Provider Specialty Information . . . . . . . . . . . . .N3 Billing Provider Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .N4 Billing Provider City/State/Zip . . . . . . . . . . . . . . . . . . . . . . . . . .SBR Subscriber Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CLM Claim Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DTP Date - Date Last Seen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DTP Date - Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PWK Claim Supplemental Information. . . . . . . . . . . . . . . . . . . . . .AMT Total Purchase Service Amount . . . . . . . . . . . . . . . . . . . . . .REF Mammography Certification Number . . . . . . . . . . . . . . . . . . .CR2 Spinal Manipulation Information . . . . . . . . . . . . . . . . . . . . . . .CRC Patient Condition Information - Vision . . . . . . . . . . . . . . . . . .PRV Referring Provider Specialty Information . . . . . . . . . . . . . . . .NM1 Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . .April 5, 20106162626363636464656566666767676969697070705
HighmarkProvider EDI Reference GuideTable of ContentsPRV Rendering Provider Specialty Information . . . . . . . . . . . . . . .NM1 Service Facility Location . . . . . . . . . . . . . . . . . . . . . . . . . . . .N3 Service Facility Location Address . . . . . . . . . . . . . . . . . . . . . . .N4 Service Facility Location City/State/Zip . . . . . . . . . . . . . . . . . . .SBR Other Subscriber Information. . . . . . . . . . . . . . . . . . . . . . . . .AMT COB Patient Paid Amount. . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SV1 Service Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .AMT Sales Tax Amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PS1 Purchase Service Information. . . . . . . . . . . . . . . . . . . . . . . . .LIN Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CTP Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Rendering Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . .PRV Rendering Provider Specialty Information . . . . . . . . . . . . . . .REF Service Facility Location Secondary Identification . . . . . . . . .PRV Referring Provider Specialty Information . . . . . . . . . . . . . . . .Chapter 9 Institutional Claim (837I)71717272737475767777777878787979819.1 General Information and Guidelines for Submitting an 837I . . . . . 839.1.1 Patient with Coverage from an Out-of-State Blue Cross BlueShield Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 839.1.1.1 KHP Central Out-of-Area Claims (Western Region). . . . . . . 839.1.2 Data that is Not Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 849.1.3 Transaction Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 859.1.4 Number of Lines per Claim. . . . . . . . . . . . . . . . . . . . . . . . . . 859.1.5 Suffix on Highmark’s NAIC Code . . . . . . . . . . . . . . . . . . . . . 859.1.6 Standalone Major Medical . . . . . . . . . . . . . . . . . . . . . . . . . . 859.1.7 Provider Identification Numbers . . . . . . . . . . . . . . . . . . . . . . 869.1.8 Claim Submission Acknowledgment . . . . . . . . . . . . . . . . . . 869.1.9 National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . . . . . 869.1.10 Balancing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 889.1.11 Real Time Claim Adjudication and Estimation . . . . . . . . . . 889.1.11.1 Real-Time 837 Submission Limitations . . . . . . . . . . . . . . . 899.1.11.2 General Requirements and Best Practices . . . . . . . . . . . . 899.2 Data Detail for 837I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 906April 5, 2010
HighmarkProvider EDI Reference GuideTable of ContentsGS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90REF Transmission Type Identification . . . . . . . . . . . . . . . . . . . . . . 92NM1 Submitter Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92NM1 Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93PRV Billing/Pay-To Provider Specialty Information . . . . . . . . . . . . 93N3 Billing Provider Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93N4 Billing Provider City/State/Zip . . . . . . . . . . . . . . . . . . . . . . . . . . 94SBR Subscriber Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94NM1 Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95NM1 Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95NM1 Patient Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96CLM Claim Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96DTP Discharge Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97DTP Admission Date / Hour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97PWK Claim Supplemental Information. . . . . . . . . . . . . . . . . . . . . . 98CN1 Contract Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99REF Original Reference Number (ICN/DCN) . . . . . . . . . . . . . . . . . 99K3 File Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100HI Principal Procedure Information . . . . . . . . . . . . . . . . . . . . . . . . 101HI Other Procedure Information. . . . . . . . . . . . . . . . . . . . . . . . . . . 102HI Value Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102NM1 Attending Physician, Operating Physician, and Other ProviderName . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103PRV Attending Physician Specialty Information . . . . . . . . . . . . . . 104NM1 Service Facility Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104N3 Service Facility Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104N4 Service Facility City/State/Zip Code . . . . . . . . . . . . . . . . . . . . 105SBR Other Subscriber Information. . . . . . . . . . . . . . . . . . . . . . . . 105NM1 Other Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106LIN Drug Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106CTP Drug Pricing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107NM1 Attending Physician, Operating Physician, and Other ProviderName . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107April 5, 20107
Table of ContentsHighmarkProvider EDI Reference GuideChapter 10 Claim Acknowledgment (277)10910.1 General Information and Guidelines for 277 Claim Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11010.1.1 Identifying the 837 in the 277 Claim Acknowledgment. . . 11010.1.2 Front-End Editing: Level Types 1-5 . . . . . . . . . . . . . . . . . 11010.1.3 Text Format Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11110.1.4 Timeframe for Batch 277 Claim Acknowledgment . . . . . . 11210.1.5 Specifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11210.1.6 Real-Time Claim Acknowledgment . . . . . . . . . . . . . . . . . 11210.1.6.1 Claim Adjudication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11210.1.6.2 Claim Estimation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11310.1.6.3 General Requirements and Best Practices . . . . . . . . . . . 113Chapter 11 Claim Payment Advice (835)11511.1 General Information and Guidelines for 835 . . . . . . . . . . . . . . . 11611.1.1 Missing Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11611.1.2 Administrative Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . 11611.1.3 Availability of Payment Cycle 835 Transactions (Batch) . 11611.1.4 Highmark Private Business and Medicare Supplemental. 11711.1.5 Highmark Major Medical. . . . . . . . . . . . . . . . . . . . . . . . . . 11711.1.6 Highmark Oral Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . 11711.1.7 Unavailable Claim Data . . . . . . . . . . . . . . . . . . . . . . . . . . 11711.1.8 Claim Overpayment Refunds . . . . . . . . . . . . . . . . . . . . . . 11811.1.8.1 Institutional Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11811.1.8.2 Professional Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11911.1.9 Electronic Funds Transfer (EFT) . . . . . . . . . . . . . . . . . . . 12011.1.10 Capitation Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . 12011.1.11 Member Identification Numbers . . . . . . . . . . . . . . . . . . . 12011.1.12 Data that is Not Used . . . . . . . . . . . . . . . . . . . . . . . . . . . 12011.1.13 National Provider Identifier (NPI) . . . . . . . . . . . . . . . . . . 12111.1.14 Provider Payments from Member Health Care Accounts12211.1.15 Real-Time 835 Response. . . . . . . . . . . . . . . . . . . . . . . . 12411.1.15.1 Real-Time Response for Claim Adjudication . . . . . . . . . 12411.1.15.2 Real-Time 835 Response for Claim Estimation . . . . . . . 12511.1.15.3 General Requirements and Best Practices . . . . . . . . . . 12711.2 Data Detail for 835 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288April 5, 2010
HighmarkProvider EDI Reference GuideTable of ContentsGS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . .BPR Financial Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Receiver Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Additional Payer Identification . . . . . . . . . . . . . . . . . . . . . . .N1 Payee Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Payee Additional Identification . . . . . . . . . . . . . . . . . . . . . . .LX Header Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CLP Claim Payment Information . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Service Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Other Claim Related Identification . . . . . . . . . . . . . . . . . . . .SVC Service Payment Information . . . . . . . . . . . . . . . . . . . . . . . .PLB Provider Adjustment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Chapter 12 Claim Status (276 & 277)12913013113113213213313313413413513613912.1 General Instructions and Guidelines for 276 and 277. . . . . . . . 14112.1.1 General Instructions and Guidelines for 276 . . . . . . . . . . 14112.1.1.1 General Description . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14112.1.1.2 Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14112.1.1.3 Data that Is Not Used . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14212.1.1.4 Minimum Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . 14212.1.1.5 Situational Elements and Data Content . . . . . . . . . . . . . . 14312.1.1.6 Requests Per Transaction Mode . . . . . . . . . . . . . . . . . . . 14312.1.1.7 Patient with Coverage from an Out-of-State Blue Cross BlueShield Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14412.1.2 General Instructions and Guidelines for 277 . . . . . . . . . . 14412.1.2.1 General Description of 277 . . . . . . . . . . . . . . . . . . . . . . . . 14412.1.2.2 Claim Splits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14512.1.2.3 Customer Service Requests . . . . . . . . . . . . . . . . . . . . . . . 14512.1.2.4 Maximum Claim Responses per Subscriber/Patient/Dependent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14512.1.2.5 Corrected Subscriber and Dependent Level . . . . . . . . . . 14512.1.2.6 National Provider Identifier . . . . . . . . . . . . . . . . . . . . . . . . 14512.2 Data Detail for 276 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146GS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Payer Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Information Receiver Name . . . . . . . . . . . . . . . . . . . . . . . . .April 5, 20101461471489
Table of ContentsHighmarkProvider EDI Reference GuideNM1 Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Subscriber Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Payer Claim ID Number . . . . . . . . . . . . . . . . . . . . . . . . . . . .14814914912.3 Data Detail for Claim Status Response (277) . . . . . . . . . . . . . . 150GS Functional Group Header . . . . . . . . . . . . . . . . . . . . . . . . . . . .NM1 Provider Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .REF Payer Claim Identification Number . . . . . . . . . . . . . . . . . . . .150151151Chapter 13 Eligibility Request-270 / Response-271 15313.1 General Instructions and Guidelines for 270 and 271. . . . . . . . 15413.1.1 Highmark Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . 15413.1.2 Dental and Oral Surgery Inquiries . . . . . . . . . . . . . . . . . . 15413.1.3 Definition of Active Coverage . . . . . . . . . . . . . . . . . . . . . . 15413.1.4 Benefit Inquiries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15413.1.5 Allowable Time Frames for Inquiries . . . . . . . . . . . . . . . . 15513.1.6 Disclaimers . . . . . . . . . . . . . . . . . . . . . . . .
Provider EDI Reference Guide April 5, 2010 The Provider EDI Reference Guide addresses how Providers, or their . 14 April 5, 2
