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Provider EDIReference GuideforBlue CrossBlue Shield ofDelawareHighmark EDI OperationsJanuary 5, 2011 Highmark is a registered mark of Highmark Inc.
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Table of ContentsChapter 1 Introduction71.1 Supported EDI Transactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.1.1 General Requirements and Best Practices . . . . . . . . . . . . . . . . 8Chapter 2 General Information112 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.1 System Operating Hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.2 Provider Information Management . . . . . . . . . . . . . . . . . . . . . . . . 122.3 Valid Characters in Text Data (AN, string data element type) . . . 12Chapter 3 Security Features133.1 Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133.2 Authorized Release of Information . . . . . . . . . . . . . . . . . . . . . . . . 13Chapter 4 Authorization Process154.1 Where to Get Enrollment Forms to Request a Trading Partner ID 154.2 Receiving 835 Transactions Generated from the Payment Cycle(Batch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164.3 Adding or Deleting a Provider on an Existing Trading Partner . . . 164.4 Reporting Changes in Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Chapter 5 Web-Based Testing PolicyJanuary 5, 2011173
DelawareProvider EDI Reference GuideTable of ContentsChapter 6 Communications196.1 Internet File Transfer Protocol (FTP) through “eDelivery” . . . . 19Chapter 7 Transmission Envelopes217.1 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217.1.1 Delimiters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217.2 Data Detail and Explanation of Incoming ISA to Highmark. . . . . . 24ISA Interchange Control Header (Incoming). . . . . . . . . . . . . . . . . .247.3 Data Detail and Explanation of Outgoing ISA from Highmark . . . 25ISA Interchange Control Header (Outgoing). . . . . . . . . . . . . . . . . .257.4 Outgoing Interchange Acknowledgment TA1 Segment . . . . . . . . 267.5 Outgoing Functional Acknowledgment 997 Transaction. . . . . . . . 26Chapter 8 Professional Claim (837P)298.1 General Information and Guidelines for Submitting an 837P . . . . 298.1.1 Transaction Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 298.1.2 Claim Submission Acknowledgment . . . . . . . . . . . . . . . . . . 298.2 Data Detail for 837P . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Chapter 9 Institutional Claim (837I)339.1 General Information and Guidelines for Submitting an 837I . . . . . 339.1.1 Transaction Size. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339.1.2 Number of Lines per Claim. . . . . . . . . . . . . . . . . . . . . . . . . . 339.1.3 Claim Submission Acknowledgment . . . . . . . . . . . . . . . . . . 33Chapter 10 Claim Acknowledgment (277)3910.1 General Information and Guidelines for 277 Claim Acknowledgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3910.1.1 Identifying the 837 in the 277 Claim Acknowledgment. . . . 3910.1.2 Text Format Options. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4010.1.3 Timeframe for Batch 277 Claim Acknowledgment . . . . . . . 404January 5, 2011
DelawareProvider EDI Reference GuideChapter 11 Claim Payment Advice (835)Table of Contents4111.1 General Information and Guidelines for 835 . . . . . . . . . . . . . . . . 4111.1.1 Missing Checks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4111.1.2 Availability of Payment Cycle 835 Transactions. . . . . . . . . 4111.1.3 Unavailable Claim Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 4211.1.4 Electronic Funds Transfer (EFT) . . . . . . . . . . . . . . . . . . . . 4211.1.5 Capitation Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4211.1.6 Member Identification Numbers . . . . . . . . . . . . . . . . . . . . . 4211.2 Data Detail for 835 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42January 5, 20115
Table of Contents6DelawareProvider EDI Reference GuideJanuary 5, 2011
DelawareProvider EDI Reference GuideChapter 1 Introduction1 IntroductionThe Provider EDI Reference Guide addresses how Providers, or theirbusiness associates, conduct Professional Claim, Institutional Claim,Claim Acknowledgment, and Claim Payment Advice, HIPAA standardelectronic transactions with Highmark. This guide also applies to theabove referenced transactions that are being transmitted to Highmarkby a clearinghouse.An Electronic Data Interchange (EDI) Trading Partner is defined asany Highmark customer (Provider, Billing Service, Software Vendor,Employer Group, Financial Institution, etc.) that transmits to, orreceives electronic data from, Highmark.Highmark’s EDI transaction system supports transactions adoptedunder the Health Insurance Portability and Accountability Act of 1996(HIPAA) as well as additional supporting transactions as described inthis guide. Highmark EDI Operations supports transactions for multiplepayers, including Blue Cross Blue Shield of Delaware (BCBSD).While Highmark EDI Operations will accept HIPAA complianttransactions from any covered entity, HIPAA security requirementsdictate that proper procedure be established in order to secure access todata. As a result, Highmark has a process in place to establish anElectronic Trading Partner relationship. That process has two aspects:January 5, 2011 A Trading Partner Agreement must be submitted which establishesthe legal relationship and requirements. This is separate from aparticipating provider agreement. Once the agreement is received, the Trading Partner will be sent alogon ID and password combination for use when accessingHighmark’s EDI system for submission or retrieval of transactions.This ID is also used within EDI Interchanges as the ID of theTrading Partner. Maintenance of the ID and password by theTrading Partner is detailed in the security section of this document.7
Chapter 1 IntroductionSupported EDI TransactionsDelawareProvider EDI Reference Guide1.1 Supported EDI TransactionsHighmark will be supporting the following EDI Transactions:Provider Transactions837 TransactionTwo implementations of this transactionfor BCBSD: Institutional 835 TransactionProfessionalClaim Payment/Advice (ElectronicRemittance)Employer/Sponsor Transactions834 TransactionBenefit Enrollment and MaintenanceAcknowledgment Transactions1.1.1TA1 SegmentInterchange Acknowledgment997 TransactionFunctional Group Acknowledgment277 AcknowledgmentClaim Acknowledgment to the 837(Provider Transaction)General Requirements and Best PracticesTrading Partners must use the ASC X12 National ImplementationGuides adopted under the HIPAA Administrative SimplificationElectronic Transaction rule and Highmark's EDI Reference guidelinesfor development of the EDI transactions. These documents may beaccessed through Blue Cross Blue Shield of Delaware’s EDI TradingPartner Portal:https://www.highmark.com/edi-bcbsdeTrading Partners must use the most current national standard code listsapplicable to the EDI transactions. The code lists may be accessed atthe Washington Publishing Company website:http://www.wpc-edi.com8January 5, 2011
DelawareProvider EDI Reference GuideChapter 1 IntroductionSupported EDI TransactionsThe applicable code lists and their respective X12 transactions are asfollows:January 5, 2011 Claim Adjustment Reason Codes and Remittance Advice RemarkCodes (835) Claim Status Category Codes and Claim Status Codes (277 ClaimAcknowledgement) Provider Taxonomy Codes (837)9
Chapter 1 IntroductionSupported EDI Transactions10DelawareProvider EDI Reference GuideJanuary 5, 2011
DelawareProvider EDI Reference GuideChapter 2 General InformationContact Information2 General InformationEDI specifications, including this reference guide, can be accessedonline at: https://www.highmark.com/edi-bcbsdeContact InformationContact information for EDI Operations:Address: EDI OperationsP.O. Box 890089Camp Hill, PA 17089-0089orTELEPHONE NUMBER:EMAIL ADDRESS:(717) 302-5170 or(800) 992-0246edisupport@highmark.comWhen contacting EDI Operations have your Trading Partner Numberand Logon ID available. These numbers facilitate the handling of yourquestions.Inquiries pertaining to Blue Cross Blue Shield of Delaware (BCBSD)claims processing should be referred to BCBSD Provider Service at(800) 346-6262.EDI Operations personnel are available for questions from 8:00 a.m. to5:00 p.m. ET, Monday through Friday.2.1 System Operating HoursHighmark is available to handle EDI transactions 24 hours a day sevendays a week, except during scheduled system maintenance periods.We strongly suggest that Highmark EDI Trading Partners transmit anytest data during the hours that Highmark EDI Operations support isavailable.January 5, 201111
Chapter 2 General InformationProvider Information ManagementDelawareProvider EDI Reference Guide2.2 Provider Information ManagementInquiries pertaining to BCBSD providers should be referred to BCBSDProvider Relations at (302) 421-8700.2.3 Valid Characters in Text Data (AN,string data element type)For data elements that are type AN, "string", Highmark can acceptcharacters from the basic and extended character sets with thefollowing exceptions:Character! NameExclamation pointGreater thanCaretPipeTildeHex value(21)(3E)(5E)(7C)(7E)These five characters are used by Highmark for delimiters on outgoingtransactions and control characters for internal processing and thereforewould cause problems if encountered in the transaction data. Asdescribed in the X12 standards organization's Application ControlStructure document (X12.6), a string data element is a sequence ofcharacters from the basic or extended character sets and contains atleast one non-space character. The significant characters shall be leftjustified. Leading spaces, when they occur, are presumed to besignificant characters. In the actual data stream trailing spaces shouldbe suppressed. The representation for this data element type is AN.12January 5, 2011
DelawareProvider EDI Reference GuideChapter 3 Security FeaturesConfidentiality3 Security FeaturesHighmark EDI Operations personnel will assign Logon IDs andPasswords to Trading Partners. EDI Transactions submitted byunauthorized Trading Partners will not be accepted by our HighmarkEDI Operations system.Trading Partners should protect password privacy by limitingknowledge of the password to key personnel. Passwords should bechanged regularly; upon initial usage and then periodically throughoutthe year. Also, the password should be changed if there are personnelchanges in the Trading Partner office, or at any time the TradingPartner deems necessary.Password requirements include: Password must be 8 characters in length. Password must contain a combination of both numeric and alphacharacters. Password cannot contain the Logon ID. Password must be changed periodically.3.1 ConfidentialityHighmark and its Trading Partners will comply with the privacystandards for all EDI transactions as outlined in the Highmark EDITrading Partner Agreement.3.2 Authorized Release of InformationWhen contacting EDI Operations concerning any EDI transactions, youwill be asked to confirm your Trading Partner information.January 5, 201113
Chapter 3 Security FeaturesAuthorized Release of Information14DelawareProvider EDI Reference GuideJanuary 5, 2011
DelawareProvider EDI Reference GuideChapter 4 Authorization ProcessWhere to Get Enrollment Forms to Request a Trading Partner ID4 Authorization ProcessNew Trading Partners wishing to submit EDI transactions must submitan EDI Transaction Application to Highmark EDI Operations.The EDI Transaction Application process includes review andacceptance of the appropriate EDI Trading Partner Agreement. If youalready have a Trading Partner relationship with Highmark, you muststill submit an application for a new Trading Partner number for BlueCross Blue Shield of Delaware business, but a new Agreement is notrequired.Submission of the EDI Transaction Application indicatescompliance with specifications set forth by Highmark for thesubmission of EDI transactions. This form must be completed by anauthorized representative of the organization.Highmark may terminate this Agreement, without notice, ifparticipant’s account is inactive for a period of six (6) consecutivemonths.Complete and accurate reporting of information will insure that yourauthorization forms are processed in a timely manner. If you needassistance in completing the EDI Transaction Application contact yourcompany’s technical support area, your software vendor, or EDIOperations.Upon completion of the authorization process, a Logon ID andPassword will be assigned to the Trading Partner. EDI Operations willauthorize, in writing, the Trading Partner to submit production EDItransactions.Test files may be submitted at the discretion of the Trading Partner.4.1 Where to Get Enrollment Forms toRequest a Trading Partner IDTo receive a Trading Partner ID, you must complete an online EDITransaction Application and agree to the terms of Highmark's EDITrading Partner Agreement. The EDI Transaction Applications and allother EDI request forms are available through the enrollment center onour Internet website. You may access the online Application from theBCBSD EDI Trading Partner Business Center page at:https://www.highmark.com/edi-bcbsdJanuary 5, 201115
Chapter 4 Authorization ProcessReceiving 835 Transactions Generated from the Payment Cycle (Batch)DelawareProvider EDI Reference Guide4.2 Receiving 835 Transactions Generatedfrom the Payment Cycle (Batch)If you are not currently receiving 835 remittance transactions generatedfrom the payment cycle in a batch process and wish to, you will need tosubmit a request to "Update Claims Transactions" by completing arequest form to update their EDI Trading Partner on the BCBSD EDITrading Partner Business Center website at:http://www.highmark.com/edi-bcbsde4.3 Adding or Deleting a Provider on anExisting Trading PartnerTrading Partners currently using electronic claim submission who wishto make Provider Changes to their Trading Partner should complete arequest form to Update their EDI Trading Partner on the BCBSD EDITrading Partner Business Center website at:https://www.highmark.com/edi-bcbsde4.4 Reporting Changes in StatusTrading Partners changing their demographic or transactioninformation must inform EDI Operations by completing theappropriate Trading Partner update request form on the BCBSD EDITrading Partner Business Center website at:https://www.highmark.com/edi-bcbsde16January 5, 2011
DelawareProvider EDI Reference GuideChapter 5 Web-Based Testing Policy5 Web-Based Testing PolicyWeb-based syntax and validation testing is done using a Highmarkcustomized version of Foresight Corporation’s HIPAA CommunityManager product. Web-based testing is available for claims whereBCBSD Interchange Receiver ID (ISA08) is either 00570 or 00070.This testing includes the following types of edits: Transaction syntax testing (4010 transaction standards), HIPAA data requirements testing (4010A1 AddendaImplementation Guides).This Web-based testing is available free of charge to our tradingpartners who have executed a new EDI Trading Partner Agreement.This functionality is designed to make EDI HIPAA syntax andvalidation testing for Highmark fast, simple, and secure by using aWeb-based environment. Testing partners will receive detailed erroranalysis reports or a notice of successful validation. For moreinformation on Foresight’s Community Manager, please visit theirWeb site describing the product at http://foresightcorp.com.If you need assistance during your Community Manager testing, youmay call EDI Operations at 800-992-0246 or e-mail us atedisupport@highmark.com. A member of our support staff will beavailable Monday through Friday 8:00 a.m. to 5:00 p.m. ET to assistwith any HIPAA Community Manager Trading Partner testingquestions you may have.To get started, you need a Highmark Trading Partner ID. This requirescompletion of an EDI Transaction Application and execution of an EDITrading Partner Agreement as explained in section 4.1. TheTransaction Application includes a place to request access to the Webbased testing function.January 5, 201117
Chapter 5 Web-Based Testing Policy18DelawareProvider EDI Reference GuideJanuary 5, 2011
DelawareProvider EDI Reference GuideChapter 6 Communications6 Communications6.1 Internet File Transfer Protocol (FTP) through“eDelivery”The Highmark Secure FTP Server (“eDelivery”) provides an FTPservice over an encrypted data session providing “on-the-wire” privacyduring file exchanges. This service offers an Internet accessibleenvironment to provide the ability to exchange files with customers,providers, and business partners using a simple FTP process in anencrypted and private manner.Any state of the art browser can be used to access the Highmark SecureFTP Server. Browsers must support strong encryption (128 bit) andmust allow cookies for session tracking purposes. Once the browsercapabilities are confirmed, the following are the general guidelines forexchanging files.1. Launch your web browser. Highmark has tested Internet Explorer6.x and Netscape 7.x browsers.2. Connect to the FTP servers at: https://ftp.highmark.com3. The server will prompt for an ID and Password. Use the ID/Password that Highmark has provided you for accessing thisservice. Enter the ID, tab to password field and enter the password,then hit enter or click on OK.4. The server will then place you in your individual file space on theFTP server. No one else can see your space and you cannot accessthe space of others. You will not be able to change out of yourspace.5. You will need to change into the directory for the type of file youare putting or getting from the server.6. By default, the file transfer mode will be binary and this mode isacceptable for all data types. However, you may change betweenASCII and Binary file transfer modes by clicking the “Set ASCII”/”Set Binary” toggle button.7. Send Highmark a file. The following is an example of thesubmission of an 837 claim transaction file:a. Click on the “hipaa-in” folder to change into that directory.b. Click on the browse button to select a file from your system tosend to Highmark. This will pop open a file finder box listingthe files available on your system.January 5, 201119
Chapter 6 CommunicationsDelawareProvider EDI Reference Guidec. Select the file you wish to send to Highmark and Click on OK.d. This will return you to the browser with the file name youselected in the filename window. Now click on the “UploadFile” button to transfer the file to Highmark. Once completed,the file will appear in your file list.8. Retrieve a file from Highmark. The following is an example ofretrieval of a 997 Functional Acknowledgment file:a. Click on the “hipaa-out” directory.b. Your browser will list all the files available to you.c. Click on the “997” directory.d. Click on the file you wish to download. Your browser willdownload the file. If your browser displays the file instead ofdownloading, click the browser back button and click on thetools next to the file you wish to receive. Select application/octet-stream. Your system may then prompt you for a “SaveAs” file location window. Make the selection appropriate foryour system and click on Save to download the file.20January 5, 2011
DelawareProvider EDI Reference GuideChapter 7 Transmission EnvelopesGeneral Information7 Transmission Envelopes7.1 General InformationInterchange Control (ISA/IEA) and Function Group (GS/
Provider EDI Reference Guide January 5, 2011 7 1 Introduction The Provider EDI Reference Guide addresses how Providers, or their business associates, conduct Professional Claim, Institutional Claim, Claim Acknowledgment, and Claim Payment Advice, HIPAA standard electronic transactions with
