July Subject: Changes for the Institutional 837 and 835 Companion Document. Dear software developer,

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1 July 2012 Subject: Changes for the Institutional 837 and 835 Companion Document Dear software developer, A revised, updated copy of the ANSI ASC X12N 837 & 835 Institutional Health Care Claim & Health Care Claim Payment/Advice (BCBSM EDI Institutional 837/835 Companion Document) is now online at: The table below summarizes the changes to companion document. Section Description of Change Page Data Clarifications for the Institutional 837 (005010X223A2) Transaction Set Loop 2010BB, NM109 Revised Payer Identifier for Medicare 10 Loop 2300, REF02 Qualifier F8 Revised instruction 11 Loop 2300 HI01-2 through HI12-2 Qualifier BE Revised instruction 11 If you have any questions regarding this information, please call our Electronic Data Interchange department at Sincerely, John Bialowicz Manager, ETP Contracting and Relations e-business Interchange Group

2 American National Standards Institute (ANSI) ASC X12N 837 (005010X223A2) Health Care Claim: Institutional Published December 2010 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

3 American National Standards Institute (ANSI) ASC X12N 837 (005010X223A2) Institutional Health Care Claim and 835 ( A1) Health Care Claim Payment/Advice Table of Contents Table of Contents... 1 Introduction... 2 ANSI ASC X12N Institutional 837 (005010X223A2) Reporting Instruction Clarifications... 3 General Overview... 3 BCN Advantage claims must be submitted as BCN claims, following BCN reporting instructions Maximums/Limitations... 3 Coordination of Benefits (COB)... 3 Institutional Electronic Claim Exceptions... 4 ANSI ASC X12N Institutional 835 (005010X221A1) Remittance Clarifications... 4 TA1 Interchange Acknowledgements Functional Acknowledgements... 4 Data Clarifications for the Institutional 835 (005010X223A2) Transaction Set... 5 Pertinent information regarding Loop 2100 REF01*CE/Type of Payment Indicator... 5 Institutional 837 and 835 Interchange Envelope and Functional Group Structure... 8 Data Clarifications for the Institutional 837 (005010X223A2) Transaction Set... 9 General EDI Terminology Blue Cross Blue Shield of Michigan Published Grand River Page 1 of 14 New Hudson, MI BCBSM 2010

4 American National Standards Institute (ANSI) ASC X12N 837 (005010X223A2) Institutional Health Care Claim and 835 ( A1) Health Care Claim Payment/Advice Introduction This document is the property of Blue Cross Blue Shield of Michigan (BCBSM) and is for use solely in your capacity as a trading partner exchanging health care transactions with BCBSM. This document provides information related to specific elements within the ANSI ASC X12N X223 and X12N X223A2 transaction set TR3, but does not change the definition, data condition, or use of a data element or segment in a standard, add data elements or segments to the maximum defined data set, use any code or data elements that are either marked not used in the standard s implementation specification or are not in the standard s implementation specification(s), or change the meaning or intent of the HIPAA standards implementation specifications. 1. This document is intended for use as a companion to the HIPAA-mandated ANSI ASC X12N Institutional 837 and 835 version X223A2 transaction set Technical Reports Type 3s. Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the applicable HIPAA TR3s published by Washington Publishing Company, companion documents, institutional manuals, and/or other billing guidelines published by our clearinghouse payers, including BCBSM. TR3s can be purchased from the Washington Publishing Company web site at Copyright (c) 2006, Data Interchange Standards Association on behalf of ASC X12.Format (c) 2000, Washington Publishing Company. All Rights Reserved. This document is incorporated by reference in the EDI Trading Partner Agreement. All instructions were written as known at the time of publication and are subject to change. Changes will be communicated in future letters and on the BCBSM web site: Appropriate steps must be taken before submitting production addenda ANSI ASC X12N transactions, such as testing, completion of an EDI Trading Partner Agreement and demographic confirmation with our customer support staff. To begin this process, receive more information or ask questions, please contact the EDI Help Desk at Standards for Electronic Transactions, Federal Register, Vol. 65, No. 160, August 17, 2000 pg Blue Cross Blue Shield of Michigan Published Grand River Page 2 of 14 New Hudson, MI BCBSM 2010

5 ANSI ASC X12N Institutional 837 (005010X223A2) Reporting Instruction Clarifications General Overview The BCBSM EDI Clearinghouse accepts ANSI ASC X12N 837 version X223A2 Institutional transactions for BCBSM (including Blue Card), Medicare Advantage 2, BCN 3, Federal Employee Program (FEP), Medicare A and Medicaid (MDCH) carriers. Acceptance of 837 and return of 835 transactions will occur in batch mode and will not be accommodated in the real-time environment. BCBSM may edit data submitted beyond the requirements defined in the HIPAA TR3s. BCBSM may reject interchanges, functional groups or transactions that do not follow all HIPAA TR3s and BCBSM Companion Document requirements. BCBSM will reject an interchange that is submitted with a submitter identification number that is not authorized for electronic submission. BCBSM will reject a file that is determined to be a duplicate of a previously submitted file. Trading partners should note that if the information associated with any of the claims in the 837 ST-SE batch is not correctly formatted from a syntactical perspective; all claims between the ST-SE would be rejected. Providers should consider this possible response when determining the size of their transactions. Medicare Advantage claims must be submitted as Medicare claims (following Medicare billing instructions) with the following exceptions: The Payer Identification Number, reported in Loop 2010BC NM109, must be equal to The insured s Primary Identification Number reported in NM109 of Loop 2010BA must contain the BCBSM assigned contract number, together with alpha prefix, for the insured. BCN Advantage claims must be submitted as BCN claims, following BCN reporting instructions. Maximums/Limitations Report a maximum of 99 services per claim for BCBSM and FEP. Report a maximum of 999 services per claim for BCN. Report a maximum of 450 services per claim for Medicare A and Medicare Advantage. Decimal data reported in data element 782 (Monetary Amount) is limited to a maximum length of ten characters including reported or implied place for cents (implied value of 00 after the decimal point). Note: the decimal point and leading sign, if sent, are not part of the character count. Coordination of Benefits (COB) TR3 front matter Sections and provide examples and detailed information regarding claim balancing and allowed/approved amount calculations. 2 The term Medicare Advantage hereinafter incorporates by reference Medicare Plus Blue PPO, Medicare Plus Blue Group PPO and Medicare Plus Blue PFFS plans. 3 The term BCN hereinafter incorporates by reference BCN HMO, BCN Advantage, BCN Service Company, Health Blue Living SM, Personal Blue, BCN 65, OneBlue SM, Healthy Blue HMO HRA SM, BlueElect Self Referral Option SM, MyBlue Medigap SM and BlueCaid. Page 3 of 2010

6 Institutional Electronic Claim Exceptions Please note the list below regarding claims that cannot be submitted in the Institutional 837 to BCBSM EDI until further notice: Commercial payers FEP when billing Tertiary payer COB claims FEP Bill types XX7 and XX8 Out-of-State hospitals (Non-par) for Blue Cross, BCN and FEP. Note: Submit out-of-state claims to the home Blues Plan. ANSI ASC X12N Institutional 835 (005010X221A1) Remittance Clarifications This document provides information pertaining to 835s for BCBSM, Medicare Advantage, BCN, NASCO and MOS (including FEP) One 835 transaction set reflects a single check or EFT transfer. Multiple claims can be referenced within one 835. The 835 may or may not contain responses for all services submitted within an individual claim and depends on how the claim is split by the adjudication system. Additional Information TA1 Interchange Acknowledgements Interchange Acknowledgements (TA1) are used to reply to an interchange or transmission, notify the sending trading partner of problems that were encountered in the interchange control structure, and verify the envelope information. TA1 acknowledgements are only provided when requested in the Interchange Control Header. Refer to Appendix A and B of the ANSI ASC X12N HIPAA TR3s for additional terminology, summaries and format information for the TA1 Interchange Acknowledgement. 999 Functional Acknowledgements Functional Acknowledgements (999) are used to facilitate control of EDI. Segments within the 999 are used to identify the acceptance or rejection of functional groups, transaction sets or segments. Data elements in error can also be identified. BCBSM will return 999 acknowledgements on a daily basis to verify receipt of files from trading partners; likewise, when transmitting files to trading partners, BCBSM expects to receive 999 acknowledgements to verify receipt. Refer to Appendix A and B of the ANSI ASC X12N HIPAA TR3s for additional terminology, summaries and format information for the 999 Functional Acknowledgement. Page 4 of 2010

7 Data Clarifications for the Institutional 835 (005010X223A2) Transaction Set Loop Segment/Element Instruction Industry/Element Name Pg# Header TRN02 The check number that was issued to the provider. Trace Number 77 BCBSM, NASCO and Medicare Advantage For remittance files containing all non-paid claims or a provider withhold adjustment, a unique generated check number will be returned. Header REF02 BCN Receiver Identification A N401 MOS, BCBSM and NASCO and Medicare Advantage Detroit will be returned. Payer City 90 BCN Southfield will be returned. 1000A N402 BCBSM, NASCO, BCN and Medicare Advantage MI will be returned. Payer State CLP06 BCBSM and NASCO Code values of 12 (Preferred Provider Organization (PPO) par arrangements) or 15 (Indemnity non-par arrangements) will be returned. BCN HM will be returned. Claim Filing Indicator Code BCBSM and NASCO Pertinent information regarding Loop 2100 REF01*CE/Type of Payment Indicator Voucher Codes First Position Field (not mapped or discontinued) Field Description 1 Inpatient Regular 2 Out-of-State and Michigan Non-Par 3 Outpatient Regular 4 5 BC Complementary Inpatient 6 BC Complementary Outpatient 7 Home Health Complementary 8 Skilled Nursing Facility (SNF) 9 Pay Subscriber (Modes) not mapped for NASCO/MOS A B F G J H K Bank Host Regular Inpatient (not mapped) Bank Host Inpatient Complementary Serviced Inpatient/Outpatient Equalized Inpatient/Outpatient Home Care Agency Home Care Hospital Ambulatory Surgical Facilities 126 Page 5 of 2010

8 Accommodation Codes Second Position Field (not mapped or discontinued) Field Description 0 BC-65 Outpatient Complementary 1 Regular Inpatient Hospital Admission 2 BC-65 Inpatient Hospital Admission, Full Days; admission out of country, Canada and after ninety-first day in U.S. hospitals, subsequent admission 3 Regular Outpatient 4 BC-65 Inpatient Hospital Admission, Full Days; admission out of country, Canada and after ninety-first day in U.S. hospitals, continuous admission 5 BC-65 Inpatient Deductible 6 BC-65 Inpatient Coinsurance and/or Lifetime Reserve Days Coinsurance M 7 BC-65 Deductible/Coinsurance and/or Lifetime Reserve Days Coinsurance 8 BC-65 Skilled Nursing Facility Coinsurance B Freestanding Physical Therapy Facility D Substance Abuse, Inpatient E Substance Abuse, Outpatient H BC-65 Home Health K Ambulatory Surgical Facility N P T W Skilled Nursing Facility, Full Days (Patient over 65) admitted under Medicare Skilled Nursing Facility Skilled Nursing Facility, Full Days (Patient over 65) non-medicare Admission Outpatient Psychiatric Facility Regular Home Health Care Program DRG_PPA Process Indicator (Method of Reimbursement) Third Position Field (not mapped or discontinued) Field Description B Blue Care Network C PHA Controlled Cost D Old de-par DRG G Old DRG Gain/loss pilot H Local Out of network claim. Pays at 100%. I ITS Home J BCN Outpatient Peer group 5, Ratio Cost to Charge K Trust/PPO Outpatient Peer group 5, Ratio Cost to Charge L PHA Lower of Cost to Charge M Psych Managed Care N PHA new DRG Page 6 of 2010

9 S U W X P T V PPO/Trust Ford flat rate/price Case Management/CCM extra contractual BCN Inpatient Total contract charge Traditional Inpatient total Trust/PPO Inpatient Total contract charge POS or CCP extra contractual Provider Contract Indicator Fourth Position Field (not mapped or discontinued) Field Description B Blue Care Network F Psych Managed Care (network 556) M Community Care partnership -in network N Community Care partnership -out of network P POS Q Blue Preferred Plus S Psych Managed Care (network 556) T Trust/PPO Blank PHA R Regional Community Blue Special Use Indicator Fifth Position Field (not mapped or discontinued) Field Description % Percent of PHA A Mid Michigan NOTE: The MOS Type of Payment Indicator is five characters. The first character is the Voucher Code, the second character is the Accommodation Code, the third character is the DRG-PPA Indicator, the fourth character is the Provider Contract Indicator and the fifth character is the Special Use Indicator. Page 7 of 2010

10 Institutional 837 and 835 Interchange Envelope and Functional Group Structure Trading partners should follow the Interchange Control Structure (ICS), Functional Group Structure (GS), Interchange Acknowledgement (TA1) and Functional Acknowledgement (999) guidelines for HIPAA that are located in the HIPAA TR3s in Appendices A and B. Trading partners should also follow the basic character set guidelines as set forth in the TR3s. The interchange cannot contain non-hipaa version functional groups. The following sections address specific information needed by BCBSM in order to process the ASC X12N/005010X223A2 837 Institutional Health Care Claim Transaction. This information should be used in conjunction with the ASC X12N/005010X223A2 837 Institutional Health Care Claim TR3. Transaction Set Element Instruction Pg# Institutional 837 Health Care Claim ISA05 Interchange ID Qualifier Report ZZ. C.4 Institutional 837 Health Care Claim ISA06 Interchange Sender ID Report the Federal Tax ID of the submitter. Must be C.4 registered with BCBSM EDI. Institutional 837 Health Care Claim ISA07 Interchange ID Qualifier Report ZZ. C.5 Institutional 837 Health Care Claim ISA08 Interchange Receiver ID Report C.5 Institutional 837 Health Care Claim GS02 Application Sender s Code Report the Federal Tax ID of the submitter. Must be C.7 registered with BCBSM EDI. Institutional 837 Health Care Claim GS03 Application Receiver s Code Report C.7 Institutional 837 Health Care Claim GS08 Version/Release/Industry ID Code Report X223A2 C.8 Institutional 835 Health Care Claim Payment Advice ISA05 Interchange ID Qualifier ZZ will be returned from EDI. C.4 Institutional 835 Health Care Claim Payment Advice ISA06 Interchange Sender ID will be returned from EDI. C.4 Institutional 835 Health Care Claim Payment Advice ISA07 Interchange ID Qualifier ZZ will be returned from EDI. C.4 Institutional 835 Health Care Claim Payment Advice ISA08 Interchange Receiver ID The URI (Unique Receiver ID), designated by the C.5 provider based on source of payment will be returned. Institutional 835 Health Care Claim Payment Advice GS02 Application Sender s Code One of the following application system identifiers will C.7 be reported for BCBSM-related 835 functional groups: NASCO and FEP: BCBSM NASCO BCBSM: BCBSM LOCAL INS BCN: FACETSTHG Medicare Advantage: MED ADVANTAGE MOS: BCBSM MOS Medicaid: D00111 Institutional 835 Health Care Claim Payment Advice GS03 Application Receiver s Code The payer assigned ID will be returned from EDI. C.7 Institutional 835 Health Care Claim Payment Advice GS08 Version/Release/Industry ID Code X223A2 will be returned. C.8 Page 8 of 2010

11 Data Clarifications for the Institutional 837 (005010X223A2) Transaction Set Loop Segment/Element Instruction Industry/Element Name Pg# 1000A NM109 Report the Federal Tax ID of the submitter Submitter Identifier 72 Qualifier B NM103 Report BCBSM as the receiver name. Receiver Name B NM109 Report as the receiver identification code for files directed to BCBSM as a clearinghouse or as a payer. Receiver Primary Identifier A All Use the Billing Provider HL to identify the original entity that submitted the electronic claim/encounter Billing Provider Hierarchical to the destination payer identified in Loop ID-2010BB. The billing provider entity may be a health care Level Loop provider, a billing service, or some other representative of the provider. 78 The Billing Provider HL may also contain information about the pay-to provider entity. If the pay-to provider entity is the same as the billing provider entity, then use Loop ID-2010AA. BCBSM, BCN and FEP Any entity reported other than the billing provider will not be recognized. Payments will continue to be directed to the provider indicated in corporate provider databases. If reported, the Pay-to provider will not be recognized/used. 2000A PRV01 All Payers Required when adjudication is known to be impacted by the provider taxonomy (type) code. 2000B SBR01 BCBSM Can be P, S or T. FEP Can be P or S. 2000B SBR09 Claim Filing Indicator Codes determine the destination payer to whom the claim will be routed by the EDI Clearinghouse. The code must correspond to the destination payer ID reported in loop 2010BB. For proper claim routing and adjudication use only the following codes: BL Blue Cross HM Blue Care Network MA Medicare A and Medicare Advantage MC MDCH (Medicaid) TV Title V 11 State Medical Plan (Other Non-Federal) FI Federal Employee Program (FEP) Billing Provider Specialty 80 Information Payer Responsibility Sequence 109 Number Code Claim Filing Indicator Code AB N3, N4 All MDCH (Medicaid) In most cases, use MC. TV and 11 also accepted. If recipient qualifies for more than one program, or other Michigan Department of Community Health program not listed, use MC. BCBSM, Medicare Advantage, BCN and FEP Payments will be directed to the provider address indicated in corporate provider database files. If reported, the Pay-to provider address will not be used to direct payment. Pay-To Address Pay-To Address City, State, Zip Code 96 Page 9 of 2010

12 Loop Segment/Element Instruction Industry/Element Name Pg# 2010BA NM109 All BCBSM (including Blue Card), BCN and Medicare Advantage NM109 is required. Subscriber Identification 114 Report the subscriber s identification number, including alpha prefix, without embedded spaces or special characters. FEP Must be an R followed by eight digits. Medicare Report the patient s Medicare Health Insurance Claim Number (HICN), including alpha character(s). MDCH (Medicaid) Report the member ID number assigned by MDCH. 2010BB NM103 BCBSM and Medicare Advantage Report BCBSM. Payer Name 123 BCN Report BCN FEP Report BCBSM FEP Medicare Report MEDICARE MDCH Report MEDICAID 2010BB NM109 The Payer Identifier must correspond to the Claim Filing Indicator reported in SBR09 of Loop 2000B. Payer Identifier 123 Payer If Claim Filing Report Payer Indicator Equals: ID: BCBSM BL FEP FI Medicare Advantage MA BCN HM Medicare MA MDCH MC TV 11 D CA NM103 BCBSM, BCN See additional instructions/description below. Patient Last Name CA NM104 BCBSM, BCN, MDCH and Medicare Patient first name must be at least one character. See additional instructions/description below. Patient First Name 136 Page 10 of 2010

13 Loop Segment/Element Instruction Industry/Element Name Pg# 2010CA NM103 & NM104: Additional instructions. Description Correct Incorrect Names should not contain any special characters, other than a dash ABC-E ABC&% Names should not contain more than three spaces between the first and last character A<space>C<space>E<space>G A<space>C<space>E<space>G<space>H Name should not contain more than three dashes between the first and last character A-C-E-G A-C-E-G-H Names should not contain a combination of more than three dashes and spaces between the first and last A-C<space>E-G A-C<space>E-G<space>H character Name should not contain consecutive spaces A<space>C<space>E<space>G A<space><space>DE Name should not contain consecutive dashes A-C-E-G A--DE Names should not contain a consecutive space and dash, in any combination A-C<space>E-G 2300 CLM05-1 The BCBSM clearinghouse accepts all valid NUBC bill type codes. Please refer to the NUBC manual or visit for a list of valid values. BCBSM When reporting revenue codes 0901 or 0912, use type of bill CLM05-3 The BCBSM clearinghouse accepts all valid NUBC claim frequency type codes. Please refer to the NUBC manual or visit for a list of valid values. A<space>-DE Or A-<space>DE Facility Type Code 145 Claim Frequency Code DTP03 All Payers In accordance with the TR3, an admission date cannot be present on outpatient claims. Admission Date/Hour 151 Qualifier 435 NUBC requires an Admission/Start of Care Date on inpatient, home health and hospice claims CL103 All Payers Must be 30 when billing interim claims bill type XX2 or XX3. Patient Status Code REF02 BCN When reported, the Claim Reference Number must follow the format beginning with E, M, Original Reference Number 166 Qualifier F8 or 0 (zero), followed by 11 digits. (ICN/DCN) 2300 HI03-2 Qualifier BR Qualifier BQ BCBSM and BCN Required on inpatient claims when reporting revenue codes 036X, 0490, 0499 or Principal Procedure Code Other Procedure Code HI01-4 through HI10-4 BCBSM Occurrence code 35 is required to be reported on physical therapy claims. Occurrence Code 259 Qualifier BH 2300 HI01-2 through HI12-2 Qualifier BE 2300 HI01-5 through HI12-5 Qualifier BE BCBSM For proper adjudication on all BCBSM and FEP claims, a value code for estimated responsibility is needed report A3, B3 or C3 as applicable. Value code 01 or 02 is required on inpatient claims. Value codes 01 and 02 are not allowed on the same claim. Report all other value codes as applicable. Value Codes 284 BCBSM When the type of bill is XX8, the value amount for A3, B3 or C3 must be zero. Value Code Associated Amount 285 Page 11 of 2010

14 Loop Segment/Element Instruction Industry/Element Name Pg# 2300 HI01-2 through HI12-2 BCBSM and FEP Only condition codes reported in HI01-2 through HI07-2 will be referenced by Condition Code 294 Qualifier BG adjudication. Any additional conditions codes reported will not be used by adjudication. 2330B NM103 All Payers If other payer information is known, report Other Payer Names without special characters, Other Payer Name 385 as follows: BCBSM Report BCBSM BCN Report BCN Medicare Advantage Report MED ADV FEP Report BCBSM FEP Medicare Report MEDICARE MDCH Report MEDICAID Other Payer Report the insurance company name 2400 SV201 BCBSM For Acute Hospitals and ASF s, if billing TOB 13X and 83X and reporting one or more of Service Line Revenue Code 424 the following revenue codes: , 0331, 0332, 0335, 0339, 0450, 0456, , 0489, 0510, , 0519, 0636, 0730, 0731, 0739, 0740, 0749, 0762, and 0929 then a HCPCS code is required SV202-1/SV202-2 Required for outpatient claims when an appropriate HCPCS exists for the service line item. Product/Service ID Qualifier 425 All Payers Report qualifier HP when billing HIPPS/RUGGS codes. BCBSM and FEP Continue to report J procedure codes for injections and chemotherapy drugs. BCN Report modifier 50 and units in SV205 for lab, radiology or surgical procedures SV203 BCBSM Type of bill 74X: When billing physical, occupational or speech therapy for service dates 3/1/08 and greater, report the actual number of visits using revenue codes 0420, 0430 or 0440 as applicable, and report zero for the total charges. Report the corresponding HCPCS, units and charges using revenue codes 0421, 0431 or 0441, as applicable. Use value code 80 to report the total number of days. Blue Card In accordance with billing guidelines for outpatient freestanding physical, occupational and speech therapy claims, report each type of therapy with the dates of service. If the individual dates are not reported, there could be a delay in processing BCBSM, BCN, FEP If bill type is 13X or 83X and multiple surgical HCPCS (range 10,000 through 69,999) are reported, the second and subsequent surgical HCPCS codes can be reported with a zero charge amount (do not leave element blank to indicate zero charges). Medicare Advantage For revenue codes 0022 and 0024 report a zero charge. Line Item Charge Amount 427 Page 12 of 2010

15 General EDI Terminology Addenda Refers to a version of the HIPAA mandated transaction sets which correct identified implementation issues noted in the original TR3s. ANSI X12N 835 v5010 HIPAA standardized ANSI X12N transaction format for claims remittance data. ANSI X12N 837 v5010 HIPAA standardized ANSI X12N transaction format for claims submission data. Data Segment Corresponds to a record in data processing terminology. Consists of logically related data elements in a defined sequence (defined by X12N). Each segment begins with a segment identifier, which is not a data element and one or more related data elements, which are preceded by a data element separator. Each segment ends with a segment terminator. Data Element Corresponds to a field in data processing terminology. Each data element is assigned unique reference number. Each element has a name, description, type, minimum length and maximum length. The length of an element is the number of character positions used, except as noted for numeric, decimal and binary elements. Data element types are: Nn Numeric (with an assumed number of decimal positions) R Decimal Real Number (including decimal or negative sign) ID Identifier AN Alphanumeric string DT Date TM Time Delimiter A character used to separate two data elements (or sub-elements) or to end a segment. They are specified in the interchange header segment (ISA). Once specified in the ISA, they should not be used in the data elsewhere other than as a separator or terminator. EDI An acronym for Electronic Data Interchange. Errata A list of errors with their corrections, inserted on a separate page of a published work Electronic Data Interchange The application-to-application transfer of key business information transacted in a standard format using a computer-to-computer communications link. There are typically 6 components used in order to do EDI. They are: an EDI file, a trading partner, an application file/form, translator (mapper), communications and value added network or value-added service provider. Interface The point at which two systems connect to pass data. Loops Loops are groups of semantically related segments. Data segment loops may be unbounded or bounded. Routing Separation of data based on specific criteria for subsequent transfer to an internal or external system. Page 13 of 2010

16 Technical Reports Type 3 (TR3) Documents that provide standardized data requirements and content as the specifications for consistent implementation of a standard transaction set. HIPAA TR3s are published by the Washington Publishing Company on their web site: Trading partners Entities that exchange electronic data files. Agreements are sometimes made between the partners to define the parameters of the data exchange and simplify the implementation process. Translation Software Commercial computer software that with input instructions converts a standard format to an application format or an application format to a standard format. Most translation software products also compliance check standard format files and automatically create interchange/functional acknowledgements to identify receipt and translation status of a file. Some products also offer translation capability from any format to any format. Transaction Set A transaction set is considered one business document which is composed of a transaction set header control segment, one or more data segments, and a transaction set trailer control segment. For example, one 837-transaction set is equivalent to one claim file. X12N An Accredited Standards Committee (ASC) commissioned by the American National Standards Institute (ANSI) to develop standards for Electronic Data Interchange (EDI). While X12 indicates EDI, the N identifies the Insurance Subcommittee that is responsible for developing EDI standards for the insurance industry. There is a special health care task group within this subcommittee responsible for the development of health care insurance transactions. BlueExchange A Blue Cross Blue Shield Association process through which non-claim HIPAA transactions for members from all other Blue Cross and/or Blue Shield plans can be accepted by a local host plan and routed to the home plan for processing. It also allows for receipt of 835 transactions for crossover remittances from other Blue Cross Blue Shield plans. Page 14 of 2010