Transcription
SHARES837P Companion Guide
ContentsIntroduction . 2SHARES 837 Guidelines . 2SHARES Interchange Requirements . 2Transaction Segment Delimiters and Terminators . 2Claim Matching . 2Service Line Unit Conversions . 3File Names . 3Claims Submission. 3Functional Acknowledgment – 999 Transactions . 5Tracing 999s To Inbound Files. 6Common File Rejection Reasons . 6837P Transaction Set . 7ISA Interchange Control Header . 7GS Segment . 7ST Segment. 8BHT Segment . 8Loop 1000A - Submitter Name . 9Loop 1000B - Receiver Name Information. 9Loop 2000A – Billing Provider Hierarchical Level. 10Loop 2010AA - Billing Provider Information . 10Loop 2000B - Subscriber Hierarchical Level . 11Loop 2010BA - Subscriber Information . 11Loop 2010BB - Payer Information . 12Loop 2300 - Claim Information . 12Loop 2400 - Service Line . 13Transaction Trailer Information . 141 Page
IntroductionThe SHARES 837P Companion Guide is designed to be used in conjunction with the HIPAAImplementation Guide. The SHARES companion guide defines specific requirements forthe submittal and processing of claims within the 3C Recovery and Health Care NetworkSHARES claims management system.This guide includes a sample transaction set and layout for the ASC X12N 837005010X222A1 Health Care Claim Professional transaction derived from sample MITSclaims. Currently claims submitted to the MITS system using a tilde segment delimiter will beaccepted by SHARES.SHARES 837 GuidelinesSHARES Interchange RequirementsThe following values are required as noted in the ISA/GS segments and Loops below.ISA 05 ISA 06 ISA 07 ISA 08 GS 02 GS 03 1000A NM1 09 1000B NM1 09 2010BB NM1 03 2010BB NM1 09 ZZAgency/Sender Tax ID or NPIZZSHARES837Agency/Sender Tax ID or NPISHARES837Sender Tax ID or NPISHARES837SHARESSHARESTransaction Segment Delimiters and TerminatorsRequired SHARES delimiters and terminators are listed in the table below. Claims that use other valueswill be rejected by the SHARES system.Segment DelimiterComposite Element DelimiterSegment Terminator‘*’ Asterick‘:’ Colon‘ ’ TildeClaim MatchingThe SHARES client ID (CID) is now required for all 837 transactions within the SHARES claims processingsystem. The system matches clients by the SHARES ID along with several matching iterations thatinclude the client name, date of birth and SSN. Providers are matched first by the National ProviderIdentifier (NPI). If there is no match on the NPI the system will match by the provider’s TaxpayerIdentification Number (TIN). If either the NPI or TIN are not matched the SHARES claims system has theability to match on the first 15 characters of the provider’s address. All unmatched claims will appear2 Page
on the Electronic Claims Processing Report (ECP) Inventory Report distributed to agency iPC downloaddirectories after a claims submission.Service Line Unit ConversionsThe SHARES system is unable to process decimals. With various services, whole units will now need tobe divided by 4. As an example, a previous MACSIS single 60-minute unit of service will need to bebilled as 4 15 minute units. For instance, an H0031 assessment of 1 unit 60 minutes should be billed as4 x 15 minute units within SHARES. Please refer to the handout SHARES Procedure Code Conversionsfrom MACSIS or Board Specific Levels of Care for further information.File NamesThe following file naming convention is required when submitting files. Board Acronym Provider ID Daily Increment Date Board Acronym – HAMISHARES Provider ID – DDDDDaily Increment – Starts at 01 and increments by 1 for each file sent dailyDate – YYYYMMDDExample: HAMI15870120151209.txtFile extensions should be one of the following to transmit successfully: .txt, .x12. File compression isnot supported by the SHARES system and only ASCII text will be processed.Claims SubmissionAll 837 Claim batches will be uploaded by agency staff manually through the SHARES Provider Connect(iPC) File Transfer Menu.To upload an 837 batch, follow the steps outlined below.From the Provider Connect home screen select File Transfer and then select Upload.3 Page
Click Upload.Select Browse to locate the 837 batch and choose 837 Claim from the File Type menu.After selecting the X12 837 file enter notes for agency and board reference as needed. Click Upload totransfer the batch.View the file upload status in the following screen. Additionally, a date filter can be used to viewpreviously submitted files.4 Page
Functional Acknowledgment – 999 TransactionsEach successful upload of an 837 meeting 5010 standards will generate a 999-transaction file availablefor download by the submitting agency. The 999 file will follow ANSI standards. If the 837 batch isrejected due to compliance reasons the 999 Functional Acknowledgements will be not be generated.It is the submitting agency’s responsibility to research and correct any compliance issues prior toresubmittal. If the 999 does not appear within the agency iPC download directory within an hour thefile has typically been rejected. At this point an agency should refer to EDI error checking softwaresuch as Liaison EDI Notepad or similar software to troubleshoot the error.If further assistance is needed after the local EDI error check, agencies may submit a Self-Service Centerticket to receive assistance from HCMHRSB or the software vendor.To download a 999 Transaction, follow the steps below. From the Provider Connect home screen selectFile Transfer and then select Download.Double click on the file link to view the 999 and save the viewed file to your local machine through thefile menu.5 Page
Tracing 999s To Inbound FilesThe inbound 837 filename will not be included in the resulting 999 filenames or within its segments.However, the 999 Loop 2000 AK202 Transaction Set Control Number can be traced to the 837’sTransaction Set Header ST02 (Transaction Set Control Number). See example below.Common File Rejection Reasons 1SA06 Interchange Sender ID – Agency sending less than 15 charactersGS08 Functional Group Header Industry Control Code --Missing “A1” appendixLoop 2010BA DMG02 Subscriber Demographics --Client Birthdate MissingLoop 2400 Service Line --Maximum loop requirement exceeded. SHARES only allows 50service lines per claimLoop 2000A --Agency sending Line Adjudication Information segment (SVD) withoutcorrelating Date of Adjudication (DTP) segment6 Page
837P Transaction SetISA Interchange Control HeaderThe Interchange Control Header starts and identifies an electronic interchange of functional groups.Example 124*1622* *00501*900000046*0*P*:LoopSEG IDHeaderISAElementRequiredRIndustry NameISA01RISA02ISA03RRAuthorization InformationQualifierAuthorization InformationSecurity Information QualifierISA04ISA05ISA06RRRSecurity InformationInterchange ID QualifierInterchange Sender hange ID QualifierReceiver IDInterchange DateInterchange TimeRepetition SeparatorInterchange Control VersionNumberInterchange Control NumberISA14RAcknowledgement RequestedISA15ISA16RRUsage IndicatorComponent ElementSeparatorSpecificationsInterchange Control Header00 – No Security InformationTransmitted10 Blank Spaces00 – No Authorization InformationTransmitted10 Blank SpacesZZEDI envelope Sender Identifierpublished by the sender. Stringdatatype 15 character.ZZSHARES837YYMMDDHHMM“ ”00501 – Indicates Version of ISA/IEAEnvelopePositive number identical to IEA02.Increments by 1 for each subsequentfile created each day. Resets daily.0 – TA1 Acknowledgement NotRequestedP – Production Data: Delimiter used to separatecomponents within one data structureGS SegmentThe Functional Group Header segment indicates the beginning of a functional group and providescontrol information. Segment 00000046*X*005010X222A1LoopSEG Element Required Industry NameSpecificationsIDHeader GSRFunctional Control GroupHeaderGS01RHealthcare ClaimHC7 Page
GS02RApplication Sender’s CodeGS03GS04GS05GS06RRRRApplication Receiver’s CodeCreation DateCreation TimeGroup Control NumberGS07GS08RRStandards Committee X12Industry ID CodeCode Used to Identifier unit sendinginformationSHARES837CCYYMMDDHHMMAssigned by sender. Must be identical toGE02X005010X222A1ST SegmentThe Transaction Set Header is used to indicate the start of a transaction Set and to assign a controlnumber. Segment Example: ST*837*000000045*005010X222A1LoopSEG Element Required Industry NameSpecificationsIDHeader STRTransaction Set HeaderST01RHealthcare Claim837 - Healthcare ClaimST02RTransaction SetFirst ST in GS 0001 Increments 1 Per GSControl NumberST02 and SE02 must be identical005010X222A1ST03RImplementation ReferenceBHT SegmentThe Beginning of Hierarchical Transaction segment defines the business hierarchical structure of thetransaction set and identifies the business purpose and includes reference data. Segment EGIDBHTElement RequiredIndustry NameRBeginning of HT06RRRHierarchical Structure CodeTransaction Set Purpose CodeOriginator ApplicationTransaction IdentifierTransaction Set Creation DateTransaction Set Creation TimeClaim IdentifierSpecifications001900First BHT in ST 1, Increments 1 per STCCYYMMDDHHMMCH (Chargeable)8 Page
Loop 1000A - Submitter NameThe Submitter Name Loop 1000A supplies the full name of the organization creating and formatting thetransaction. Example Segments: NM1*41*2*MH/AOD CORPORATION*****46*0012345678 PER*IC*JOHN SMITH*TE*5139468468*FX*513999999LoopSEG Element Required Industry NameSpecificationsID1000A NM1RSubmitter Name InformationNM101 REntity Identifier Code41 – Claim SubmitterNM102 REntity Type Qualifier2 – Non-Person EntityNM103 ROrganization NameString Datatype 60 Character MaxNM104 RCreation DateCCYYMMDDNM105 RCreation TimeHHMMNM108 RGroup Control Number46 - ETIN: Electronic Transmitter IDNumberNM109 RIdentification CodeSubmitter NPI or Submitter Tax ID1000A PERRSubmitter EDI ContactInformationPER01RContact Function CodeIC - Information ContactPER02SSubmitter Contact NameUser Defined String 60 Character MaxPER03RCommunication NumberTE - PhoneQualifierPER04RCommunication NumberSubmitter telephone numberPER05SCommunication NumberFX - FAXQualifierPER06SCommunication NumberSubmitter fax numberPER07SCommunication NumberEM – Electronic MailQualifierPER 08SCommunication NumberSubmitter email addressLoop 1000B - Receiver Name InformationLoop 1000B is used to supply the receiving organization’s name information. Example Segment:NM1*40*2*HAMILTON CO MHRSB*****46*SHARE837LoopSEG Element Required Industry NameSpecificationsID1000B NM1RReceiver Name InformationNM101 REntity Identifier Code40 (Receiver)NM102 REntity Type Qualifier2 (Non Person :Entity)NM103 RReceiver NameCounty Board SpecificNM108 RIdentification Code Qualifier46 (Electronic TransmitterIdentification Number - ETIN)NM109 RReceiver Primary IdentifierSHARES8379 Page
Loop 2000A – Billing Provider Hierarchical LevelThe Billing Provider Hierarchical Level identifies dependences among data segments and levels within ahierarchy. Example Segment: HL*1**20*1LoopSEG Element Required Industry NameSpecificationsID2000A HLRHierarchical LevelHL01RHierarchical ID NumberBegins with 1 and increment by 1 foreach HL used. Possible toInclude this record for each claim.HL03RHierarchical Level Code20 – Information SourceHL04RHierarchical Child Code1 (Additional Subordinate HL datasegment in this hierarchical structure)Loop 2010AA - Billing Provider Information2010AA Loop is used to define identifying information about the billing provider. This includes name,address, tax and contact Information. Example segments below:NM1*85*2*AOD/MH CORPORATION*****XX*134999999 N3*999 MAINSTREET N4*CINCINNATI*OH*45202-0001 REF*EI*310999999 PER*IC*TEXJOHNSON*TE*5139468648 LoopSEGIDElement Required2010AA NM1PER01PER02PER03RSRBilling Provider Name InformationEntity Identifier CodeEntity Type QualifierBilling Provider Organization NameID Code QualifierBilling Provider IDBilling Provider AddressBilling Provider Address Line 1Billing Provider Address Line 2Billing Provider City State ZipBilling Provider CityBilling Provider StateBilling Provider ZIP CodeBilling Provider Tax IdentificationReference Identification QualifierBilling Provider IdentifierBilling Provider ContactInformationContact Function CodeBilling Provider Contact NameCommunication QualifierPER04RCommunication NumberNM101NM102NM103NM108NM1092010AA N3N301N3022010AA N4N401N402N4032010AA REFREF01REF022010AA PERRRRRSSRRSRRSSRRRRIndustry NameSpecifications85 – Billing Provider2 – Non-Person EntityString datatype 60 char maxXXNational Provider IdentifierString datatype 55 char maxString datatype 55 char maxString datatype 30 char maxImplementation GuideImplementation GuideEIEmployer ID NumberIC – Information ContactString datatype 60 char maxEM - Electronic Mail, FX Fax, TE - TelephoneAgency Contact PhoneNumber10 P a g e
Loop 2000B - Subscriber Hierarchical LevelLoop 2000B Subscriber Hierarchical Level contains information specific to a client in the SBR segment.Segment Examples: HL*2*1*22*0 SBR*P*18*******ZZ LoopSEG Element Required Industry NameSpecificationsID2000B HLRHierarchical LevelHL01RHierarchical ID NumberIncremented by 1 from previous HLSegmentHL02RHierarchical Parent ID Number Must HL01 from previous Loop 2000AHL03RHierarchical Level Code22 - SubscriberHL04RHierarchical Child Code0 - Additional Subordinate HL datasegment in this hierarchical structure2000B SBRRSubscriber InformationSBR01RPayer Responsibility SequenceP - Primary, S -Secondary, T – TertiaryNumberor last resortSBR02SIndividual Relationship Code18 – SelfSBR09RClaim Filing Indicator CodeZZ Mutually definedLoop 2010BA - Subscriber InformationLoop 2010BA is used to provide the name, unique Identifier, location and demographics of a named partyor client. Segment Examples: NM1*IL*1*SMITH*JOHN*T***MI*299999 N3*1234 APPLECOURT N4*CINCINNATI*OH*45201 DMG*D8*19920101*M LoopSEG Element RequiredID2010BA NM1RNM101 RNM102 RNM103 RNM104 SNM105 SNM107 SNM108 SNM109 SIndustry Name2010BA N3Subscriber AddressSubscriber Address Line 1Subscriber Address Line 2Subscriber City State and ZipSubscriber City NameSubscriber State NameSubscriber ZipSubscriber DemographicsDate Format QualifierSubscriber BirthdateSubscriber GenderN301N3022010BA N4N401N402N4032010BA DMGDMG01DMG02DMG03SRSSRRRSRRRSubscriber Name InformationEntity IdentifierEntity Type QualifierSubscriber Last NameSubscriber First NameSubscriber Middle NameSubscriber SuffixID Code QualifierSubscriber Primary IdentifierSpecificationsIL (Insured)1 (Person)String datatype 60-character maxString datatype 35-character maxString datatype 25-character maxString datatype 10-character maxMI - Member IDSHARES ID/MACSIS ID The ID willcutover to SHARES ID only date TBD.String datatype 55-character maxString datatype 55-character maxString datatype 30-character maxState ID 2 charactersBilling provider Zip Code IdentifierD8 (CCYYMMDD)Client’s DOB CCYYMMDDM (Male), F (Female), U(Unknown)11 P a g e
Loop 2010BB - Payer InformationThe NM1 Section of Loop 2010BB is used to provide information about the payer organization. ExampleSegment: NM1*PR*2*SHARES*****PI*SHARESLoopSEG Element Required Industry NameSpecificationsID2010BB NM1RPayer Name InformationNM101 REntity Identifier CodePR (Payer)NM102 REntity Type Qualifier2 (Non-Person Entity)NM103 RPayer NameSHARES (currently MACSIS)NM108 RIdentification Code QualifierPI (Payer Identification)NM109 RPayer IDSHARES (currently MACSIS)Loop 2300 - Claim InformationThe Claim Information (CLM) segment defines basic data about a professional claim. The HealthcareDiagnosis segment contains the diagnosis information. Example Segments:CLM*999900N*106.65***53:B:1*Y*A*Y*Y*P HI*BK:2989LoopSEG ElementRequired Industry NameSpecificationsID2300CLMRClaim InformationCLM01RClaim Submitter’s Identifier38 Character Max – Identifier used by asubmitter for tracking. Typically echoedback in an 835CLM02RClaim Total Charge AmountMonetary Amount DecimalCLM05-1RFacility Code53 -Community Mental Health Center,11 – Office, VariesCLM05-2RFacility Code QualifierB – Place of Service CodeCLM05-3RClaim Frequency Code1 original; 6 corrected; 7 replacement8 void Removed per addendaCLM06RProvider Signature on FileY – Yes N - NoCLM07RProvider Accept CodeA - AssignedCLM08RBenefits AssignmentYCertification IDCLM09RRelease of Information CodeY (Y - Yes, Provider has signedstatement permitting release, I Informed Consent toRelease),CLM10SPatient Signature Source Code P – Signature Generated by Provider2300HISHealthcare Diagnosis CodeHI01-1RDiagnosis Code TypeABK International Classificationof Diseases, Clinical Modification ICD-10CM Principal Diagnosis or BKInternationalClassification of Diseases ClinicalModification ICD-9-CM PrincipalDiagnosisHI01-2RDiagnosis CodePrincipal Diagnosis12 P a g e
Loop 2400 - Service LineLoop 2400 describes claimed services. It defines the service line number, the professional
ISA06 R Interchange Sender ID EDI envelope Sender Identifier published by the sender. String datatype 15 character. ISA07 R Interchange ID Qualifier ZZ ISA08 R Receiver ID SHARES837 ISA09 R Interchange Date YYMMDD ISA10 R Interchange Time HHMM ISA11 R Repetition
