PacifiCare Electronic Data Interchange 278 Transaction Companion Guide Health Care Services Review Request for Review and Response to Request for Review (Version1.0 October 2003) 278 ANSI ASC X12 278 (004010X094 & 004010X094A1)
Table of Contents INTRODUCTION... 4 ASSUMPTIONS... 5 PREFERENCES AND CONVENTIONS... 6 General File Submission Requirements...6 Causes for Rejection of File Submission...6 Field Lengths and Values...7 COMMUNICATION METHODS SUPPORTED... 9 Clearinghouse...9 Direct Submission...9 TRANSACTION STRUCTURE AND PROCESSING BATCH... 9 Scope of Transaction: ST to SE...9 Batch Processing...9 TRANSACTION PROCESSING HEALTH PLAN PRODUCTION SYSTEM...10 PRIVACY AND SECURITY PROTECTION...10 ENCRYPTION REQUIREMENTS...10 HANDLING ACKNOWLEDGEMENTS...11 ANSI ASC X12 Acknowledgement...11 TA1 Interchange Acknowledgment...11 997 Functional Acknowledgment...11 GENERAL USAGE...11 SPECIFIC USAGE...12 HANDLING LIKELY SITUATIONS...13 APPENDIX A SAMPLE FILES...15 278 Scenario #1...15 278 Scenario #2...17 278 Scenario #3...20 278 Scenario #4...28 APPENDIX B TESTING REQUIREMENTS...34 APPENDIX C CROSSWALK TABLES...35 278 Comp Guide_v1 2 10/10/03
COMBINED 278 REQUEST FOR REVIEW TRANSACTION SET (004010X94 & 004010X94A1)...42 COMBINED 278 RESPONSE TO REQUEST FOR REVIEW TRANSACTION SET (004010X94 & 004010X94A1)...81 278 Comp Guide_v1 3 10/10/03
Introduction PacifiCare is publishing this Electronic Data Interchange (EDI) 278 Transaction Companion Guide (Companion Guide) to accompany the ASC X12N Combined Implementation Guide (Implementation Guide) for the ASC X12N Health Care Services Review Request for Review and Response to Request for Review (278) (004010X094 & 004010X094A1) transaction. The primary purpose of this Companion Guide is to minimize the variability in the transaction set that is exchanged within all of the regions of PacifiCare. The Companion Guide will document assumptions, conventions, and preferences that PacifiCare expects health plans, providers, and information system vendors to comply with. Additionally, the Companion Guide will help to walk organizations through the implementation process so that the resulting transaction will meet the following business objectives: 1. Convey all required business information: The transaction will convey the comprehensive set of information that is required for health plans to conduct their business. 2. Interpret information in the same way: The definition of the transaction will be specific so that Trading Partners can correctly interpret the information that is received from each other from a business perspective. 3. Simplify the communication: The transaction will be standard to simplify communication between Trading Partners as well as comply with Health Insurance Portability and Accountability Act (HIPAA) regulations. The underlying premise of the PacifiCare Companion Guide is that it defines the superset of business functionality for the Health Care Services Review Request for Review and Response to Request for Review (278) Transaction Set. The Implementation Guide provides general information about EDI transmission, such as delimiters, enveloping, and related topics. PacifiCare s document will not duplicate these efforts. In order to establish a simplified implementation environment, the Companion Guide describes a set of assumptions and conventions that will be followed by Trading Partners as they implement the 278 transaction and interpret the information that is contained within it. These conventions provide additional clarity about data structures and data elements (i.e., what they mean), and describe how these data elements relate to information contained in the information systems belonging to each Trading Partner (i.e., how they will be used). It should be noted that the Companion Guide does not add, delete, or change the name of any data element that is specified in the ASC X12N Implementation Guide. HIPAA Implementation Guides are available through Washington Publishing, Inc. at: http://www.wpc-edi.com/ 278 Comp Guide_v1 4 10/10/03
Assumptions The following assumptions are being made for purposes of this guide: The Interchange Transmission refers to an ISA/IEA. The Functional Group refers to the GS/GE. The Transaction Set refers to the ST/SE (can come in multiple functional groups). Providers or clearinghouses submitting the 278 Health Care Services Review Request for Review and Response to Request for Review transaction directly to PacifiCare must first be registered. Registration includes the exchange of important information necessary for successful e-commerce, including submitter and receiver information, connectivity specifications, etc. For most questions relating to information in this guide, contact the PacifiCare Enterprise EDI Services (EES) department at: Email: EDISupport@phs.com Fax: Telephone: 1-972-866-1690 Attn: EDI Support 1-800-203-7729 Health Care Services Review Request for Review and Response to Request for Review transactions submitted to PacifiCare, either directly or through a clearinghouse, must be compliant with HIPAA. According to HIPAA legislation, a penalty of not more than $100 for each violation, and up to $25,000 may be imposed by the U.S. Department of Health and Human Services for transactions that are not compliant. For more information, please see the U.S. Department of Health and Human Services website at: http://aspe.os.dhhs.gov/admnsimp/pl104191.htm#261 278 Health Care Service Review Request for Review and Response to Request for Review transactions submitted to PacifiCare are assumed to be production ready. The provider, clearinghouse, and system vendor(s) will have completed testing prior to submission to ensure HIPAA compliance. For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative. 278 Comp Guide_v1 5 10/10/03
Preferences and Conventions The items listed below outline specific preferences and conventions to be used when transmitting data to PacifiCare. General File Submission Requirements 1. Trading Partner Agreements specify the terms and conditions by which transactions are exchanged electronically with PacifiCare. This Companion Guide may be an addendum to a new or existing Trading Partner Agreement or other Business Agreement. 2. PacifiCare strongly recommends to every Trading Partner submitting the 278 Health Care Service Review Request for Review and Response to Request for Review - transaction directly to PacifiCare sign a Trading Partner Agreement. 3. PacifiCare will request that providers obtain certification from an approved Third-Party Certification System and Service (TPCSS), stipulating that its transactions are HIPAA compliant. For more information about certification and certification vendors, speak to the appropriate EES Project Manager, or refer to the white paper on WEDI SNIP web site: http://snip.wedi.org/public/articles/index.cfm?cat=15 4. While PacifiCare supports all of the characters in the extended character set, it is recommended that incoming 278 data use the basic character set as defined in Appendix A of the Implementation Guide. 5. Some segments and data elements labeled as Not Used in this Companion Guide, but labeled as Situational in the Implementation Guide, will still be accepted and validated to ensure HIPAA compliance. However, PacifiCare will not actually use these segments and data elements. 6. Data submitted to PacifiCare in ANSI HIPAA standard format will be translated into a proprietary format for purposes of internal processing. 7. Only multiple data loops or segments should be populated with the first occurrence, and each loop or segment populated consecutively thereafter. There should be no loops or segments without data. 8. As of the release of this document (October 2003), PacifiCare accepts the following versions of the Implementation Guide. ANSI ASC X12N 278 (004010X094 & 004010X094A1) Causes for Rejection of File Submission 1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as long as the same one is used throughout the transaction. PacifiCare s preferred characters are either : or ^. A carriage return/linefeed will cause an interchange/transmission to be rejected. 2. Only loops, segments, and data elements valid for the Implementation Guide will be translated. Submission of data that is not valid based on the Implementation Guide will cause files to be rejected. 278 Comp Guide_v1 6 10/10/03
3. If a segment or data element within a segment is specified in the Implementation Guide as Not Used, yet is present in the transaction, it will be rejected as an error. 4. PacifiCare will reject an interchange transmission if the submitter identification number in either ISA06 (Sender ID) or GS02 (Application Sender s Code) is not registered for electronic submission. 5. PacifiCare will reject a functional group or interchange transmission that is submitted with an invalid value in either ISA08 (Receiver ID) and/or GS03 (Application Receiver s Code), based on the Trading Partner agreement. Field Lengths and Values 1. REF01/128 Reference Identification Qualifier Loop 2010 B Requester Supplemental Identification Preferred values are: N5 Provider Plan Network Identification Number N7 Facility Network Identification Number 2. REF02 127 Reference Identification Loop 2010B Requester Supplemental Identification must contain the PacifiCare assigned DEC # for the Provider or the Facility. The DEC # is required to create a case in the back-end system. 3. The Dependent Information must be submitted in Loop 2000C and Loop 2000CA (Subscriber Level) because all members have unique Member ID s. The Dependent Loop 2000D and 2000DA will not be used. 4. HI01/1270 Code List Qualifier Code Loop 2000C Subscriber Diagnosis PacifiCare s back-end system (CarePlanner) requires each case to have a BK (Principal Diagnosis) as primary. 5. Loop 2000D Dependent Loop Not used by PacifiCare. Members have their own unique Member Identification. Use Loop 2000C. 6. The Servicing Provider Loop 2010E is required to create a case in the backend system. 7. REF01/128 Reference Identification Qualifier Loop 2010E Service Provider Supplemental Identification Preferred values are: N5 Provider Plan Network Identification Number N7 Facility Network Identification Number 8. REF02/127 Reference Identification Loop 2010E Servicing Provider Supplemental Identification must contain the PacifiCare assigned DEC # for the Provider or the Facility. The DEC # is required to create a case in the back-end system. 9. UM02/1322 Certification Type Codes in Loop 2000F The following Codes are Preferred Values: Appeal Immediate Appeal Standard Cancel 278 Comp Guide_v1 7 10/10/03
Extension Initial If R (Renewal) is submitted, it will be treated as an Extension. If S (Revised) is submitted, it will be treated as an Initial. 10. UM03/1365 Service Type Codes in Loop 2000F See Appendix C Table for HIPAA and Legacy crosswalk values. If not valued, then will default to Medical. 11. UM04 1/1331 Facility Code Values and UM04 2 1332 B HCFA POS (Place of Service) Codes in Loop 2000F See Appendix C Crosswalk Table 56 A Uniform Billing Claim Form Bill Type Codes (NUBC) and Crosswalk Table 56 B Healthcare Financing Administration Claim Form Codes (HCFA). NOTE: This is a required field to create a case in CarePlanner. A HIPAA value must be chosen from either Table A or Table B (based on your selection in UM04-2/1332). The value in the left column is the HIPAA value and the corresponding value in the right column will be the Treatment Setting in CarePlanner. 12. UM04 1/1338 Level of Service Code Values in Loop 2000F. NOTE: PacifiCare prefers if the request is an Emergency or Urgent to use the current method of contacting PacifiCare. 13. REF02/127 Reference Identification (Previous Certification Identifier) in Loop 2000F. The Certification number is required when submitting an Extension, Cancel or Appeal transaction. If not included, the transactions will reject. 14. HI01 1/1270 H112-1/1270 Code List Qualifier. The preferred value is BO. NOTE: The quantity value in all HI Segments will always default to 1 unless a quantity amount is specifically valued. 15. HI101-2 / 1271 HI112-2/1271 Industry Code in Loop 2000F Submission of Multiple Procedures. NOTE: Trading Partners are requested to submit one procedure in a single 2000F Service Loop. Multiple procedures may be requested by submitting multiple 2000F Service Loops with each loop containing one procedure code. If multiple procedures are submitted in a single 2000F loop, PacifiCare will reject the transaction. (Refer to Appendix A, 278 Scenario #2, Multiple Procedures.) 16. CL101/1315 Admission Type Codes Refer to Form Locator 19 codes from the UB92 Manual for Inpatient Admissions. 17. CL102/1314 Admission Source Codes Refer to Form Locator 20 Codes from the UB92 Manual for Inpatient Admissions. 18. CL103/1352 Patient Status Codes Refer to Form Locator 22 Codes from the UB92 Manual for Inpatient Admissions. 278 Comp Guide_v1 8 10/10/03
Communication Methods Supported PacifiCare supports the following communication methods: Clearinghouse For clearinghouse EDI requests, it is necessary to contact the clearinghouse directly. They will provide all of the necessary testing and submission information required. Direct Submission For direct submission of requests to PacifiCare or for details regarding communication protocols, contact the PacifiCare EES department at: Email: EDISupport@phs.com Fax: Telephone: 1-972-866-1690 Attn: EDI Support 1-800-203-7729 Transaction Structure and Processing Batch There will be a separate ISA-ISE set for each different type of transaction. For example, if an electronic transmission between two trading partners contains referrals and claims, there will be two ISA-ISE sets; one for the referrals (278) and one for the claims (837). This Companion Guide reflects conventions for batch implementation of the ANSI X12N 278 Health Care Services Review Request for Review and Response to Request for Review transaction. Scope of Transaction: ST to SE A 278 transaction, request or response, will contain information for one patient event. All information between an ST and the corresponding SE will relate to requests for procedures/services that are made by a single requesting provider for one patient. The transaction may include services requests for one or more procedures/services from multiple service providers. If the information associated with any of the service provider and/or procedures/services is not correctly formatted from a syntactical perspective, the entire transaction will be rejected. Batch Processing The 278 transactions will be batched and processed three times a day, 7:30 am, 1:30 pm, and 5:00 pm. A batch contains service information on 1-999 patient events. In most cases, there will be one and only one of each of the following segments: ISA, GS, GE, IEA. There will be up to 999 ST and SE segments. For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative. 278 Comp Guide_v1 9 10/10/03
The requesting provider, or their electronic intermediary, will send the 278 request transaction to the health plan through some means of telecommunications and will not remain connected while the health plan processes the transaction. The health plan will send the 278 response transaction to the requesting provider, or their electronic intermediary, through some means of telecommunications. The communication protocol will be defined in the Trading Partner setup form. Health plans intend to respond, with some type of acknowledgment, to every batch of 278 requests that is received. This acknowledgment will be sent whether or not the provider, or their intermediary, requests it. The acknowledgment will indicate that the 278 request was received. The acknowledgment is not intended to convey confirmation or authorization. Implementation experience will help to determine whether it is practical to always reply with acknowledgment and, if so, when the acknowledgment will be a TA1, a 997 or a 278. If some or all of the ISA segment is unreadable or does not comply with the Implementation Guide AND if there is sufficient routing information that can be extracted from the ISA, the health plan will respond with an appropriate TA.1 transaction. Otherwise, the health plan will be unable to respond. In either case, the batch will not be processed. In all other cases, the health plan will respond with an appropriate 997 transaction to acknowledge receipt of the Batch. The 997 transaction will indicate whether or not the batch can be processed. If the GS segment of the batch does not comply with the Implementation Guide, the health plan may not be able to process the transaction. If the health plan is able to process the batch, a batch of 278 responses will be sent when processing is complete. The Trading Partner will receive a positive 997 and 278. Transaction Processing Health Plan Production System Refer to the 278 Request for Review and/or 278 Response to Request for Review transaction set in this document. Privacy and Security Protection PacifiCare will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy and Security regulations regarding the need to protect health information. All Trading Partners are also expected to comply with these regulations. Encryption Requirements PacifiCare will comply with the data encryption policy as outlined in the HIPAA Privacy and Security regulations regarding the need to encrypt health information and other confidential data. All data within a transaction that is included in the HIPAA definition of Electronic Protected Health Information (ephi) will be subject to the HIPAA Privacy and Security regulations and PacifiCare will adhere to such regulations and the associated encryption rules. All Trading Partners are also expected to comply with these regulations and encryption policies. 278 Comp Guide_v1 10 10/10/03
Handling Acknowledgements ANSI ASC X12 Acknowledgement PacifiCare utilizes two forms of acknowledgements: the TA1 Interchange Acknowledgement, and the 997 Acknowledgement. Therefore, the Trading Partner can, at its discretion, request that we send: A TA1 acknowledgment (negative and positive) A 997 acknowledgement (negative and positive) Both acknowledgements or No acknowledgement at all. TA1 Interchange Acknowledgment A TA1 acknowledgment will be generated and returned to the Trading Partner to indicate the success or failure of processing a transaction from the ISA to the IEA. It will indicate whether or not there were errors at the ISA or envelope level. 997 Functional Acknowledgment The 997 Functional Acknowledgement will be sent back to the Trading Partner as determined by Trading Partner setup, to indicate the success or failure of 278 compliance validation within each GS/GE segment. PacifiCare will return 004010 as the version in GS08 (Version/Release/Industry Identifier Code) of the 997. General Usage 1. The 278 request transaction may be sent by an electronic intermediary, acting on the behalf of the requesting provider, or may be sent by the requesting provider. Information about the sender of the transaction will be placed in the ISA segment and the GS segment. Loop 2000B, Requester Level, will contain information about the Requesting Provider. The Requesting Provider will be the person or entity that is requesting the clinical services. If the sender of the transaction is an electronic intermediary acting on behalf of the requesting provider the ISA segment and the GS segment will identify the intermediary. The requesting provider will be identified in the 2000B Loop (Requester Level). Each service provider will be identified in one occurrence of the 2000E Loop (Service Provider Level). If the sender of the transaction is the requesting provider the ISA segment, the GS segment and the 2000B Loop (Requester Level) will identify the requesting provider. Each service provider will be identified in one occurrence of the 2000E Loop (Service Provider Level). 2. The Health Plans processing system will look to match a 278 request with an eligible patient. For a match to be made, either: 278 Comp Guide_v1 11 10/10/03
If the patient is a subscriber, or a dependent that has a unique member ID, an exact match is required on Member ID and Date of Birth OR Member ID and Lastname: Member Identification Number (NM109 of Loop 2010C) Date of Birth (DMG02 of Loop 2010C) Lastname (NM103 of Loop 2010C) Otherwise a not found message will be sent. 3. PacifiCare will not send back updated patient information from the PacifiCare healthcare system in the 278 response. The trading partner will receive back the exact information that was received in the original request. 4. There are various reasons why a 278 request could not be processed by the health plan. In those cases when a 278 request cannot be processed, a 278 response will be returned with appropriate AAA segment(s) that indicates the reason. 5. Before returning a 278 response, health plans will attempt to find all possible error conditions and to identify those conditions with the appropriate AAA segments. However, there are likely to be circumstances when the health plan stops processing upon reaching the first error condition that is found, and will return the 278 response with the appropriate AAA segment. ( Out of Network Provider, AAA03, is one possible example.) 6. In certain cases when PacifiCare is unable to process transaction we will send back AAA segment in the 2000A loop with the appropriate response. The following could be reasons: Multiple procedures in a single 2000F loop Unknown error Crosswalk failure Unable to process the transaction in the given time 7. If multiple procedures were requested, PacifiCare will send back the response in separate 2000F loops for each procedure (HI Segment). This will allow PacifiCare to respond with separate HSD segments for each procedure, enabling a separate determination to be made for each procedure. For example, if 3 procedures were requested on the same 278 request and the health plan approved two of them and denied one of them, then there would be three 2000F loops two with an HCR01 = A1 and the other with an HCR01 = A3. Specific Usage The Health Care Services Review Request for Review and Response to Request for Review (278) transaction set will be used to convey information about request for health services between health plans and provider organizations. The intent of this transaction is to: Allow providers to request services and procedures from health plan carriers for patients. 278 Comp Guide_v1 12 10/10/03
Allow health plans to communicate authorization or denial information pertaining to requested services and procedures (response transaction). Unfortunately, the names of these communications are not standardized. They mean different things to different people. To minimize confusion, the following definitions will be used in order to describe the scope of this transaction. A Referral is the communication between two healthcare providers about care to be delivered to a patient. In some, but not all cases, a health plan may be involved in this communication. Typically a PCP is the requesting provider and a specialist or facility is the service provider. The services can be outpatient services, inpatient services, home services, or any other services. Health plan involvement and processing of a Request varies depending upon the services to be rendered and the policies of the particular health plan as it relates to those services. In some situations, processing will vary by product line within a health plan. Typically however, processing of Requests fall into one of the following cases: No Request Required In certain circumstances, authorization may not be required for certain procedures or services. In this case, the trading partner may be sent back an HCR response with the error code of 84 Certification is Not Required for this Service. Request Required Unless otherwise stated in the Trading Partner Agreement or Provider contract, PCPs must request consent from the health plan to provide certain services or procedures to patients. If the request is approved, the trading partner will receive back a confirmation number in the HCR02 segment. This confirmation number must accompany any claims submitted to PacifiCare for payment. Eligibility, benefits, and medical necessity will be reviewed before making the final determination. If further review is needed, the provider will receive a response of A4 Pended and E8 Requires Medical Review. The provider should not render care without receiving an approved authorization from the health plan. The 278 transaction will be used in all of these cases. Handling Likely Situations 1. SITUATION: There is a difference between information contained in the 278 request and information the health plan has on file. ACTION: A 278 response will have the same information returned in the 278 response as was received in the request, even if the healthcare system has updated information. PacifiCare will not update the transaction with new or different patient data. The response will contain some additional data such as the Certification Action Code and the Certification Number. 2. SITUATION: The health plan cannot reply to a 278 request with a complete 278 response because one or more of their systems are not operational. 278 Comp Guide_v1 13 10/10/03
ACTION: The health plan will reply with a 278 response that contains an AAA segment in the 2000A Loop. The AAA03 field will contain a 42 (Unable to Respond at Current Time). 3. SITUATION: The health plan cannot uniquely match a requesting provider identified in the 278 request to a provider in their database. ACTION: The health plan will reply with a 278 response that contains an AAA segment in the 2010B Loop. The AAA03 field will contain a 51 (Provider Not on File). 4. SITUATION: The 278 request did not contain enough information about the subscriber to allow the health plan to find a unique match in their database. ACTION: The health plan will reply with a 278 response that contains an AAA segment in the 2010C Loop. The AAA03 field will contain a 15 (Required Application Data Missing). 278 Comp Guide_v1 14 10/10/03
Appendix A Sample Files 278 Scenario #1 LOS (Length of Stay) and a Procedure Request This is an example of a LOS and Procedure request for an Inpatient Admission: ST*278*1205~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*N7*006350-0003~ HL*3*2*22*1~ HI*BJ:788:D8:20031011~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*N7*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*I*2*21:A**03***Y~ DTP*435*D8*20031011~ HSD*DY*2~ (Note: Number of Days Requested is 2. ) CL1*1*1~ MSG*SCRIPT5_BUSINESS~ HL*6*4*SS*0~ TRN*1*11111111*9512367879~ UM*AR*I*2*21:A*****Y~ DTP*435*D8*20031011~ HI*BO:36000:D8:20031011~ (Note: Procedure Code and Date.) CL1*1*1~ SE*28*1205~ 278 Comp Guide_v1 15 10/10/03
Procedure Only Request ST*278*1208~ BHT*0078*13*A12345*19980908*1101~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE OUTPATIENT SURGICAL*****46*959590001~ REF*N7*012729-0001~ HL*3*2*22*1~ HI*BK:486:D8:20031003~ NM1*IL*1*FLINTSONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE OUTPATIENT SURGICAL*****46*959590001~ REF*N7*012729-0001~ PER*IC**TE*4029993456~ HL*5*4*SS*0~ TRN*1*AAA56666*9012345678~ UM*HS*I*4*13:A*****Y~ HI*BO:71020:D8:20031003~ (Note: Procedure Code & Date Qty will default to 1 unless specified.) MSG*SCRIPT11_BUSINESS~ SE*20*1208~ 278 Comp Guide_v1 16 10/10/03
278 Scenario #2 Multiple Procedures Correctly Submitted Due to the inability of the X12 278 response to provide more than one HCR (Certification Action Code) if multiple procedures are submitted in one HI segment, PacifiCare is proposing the following solution. Trading Partners are requested to submit one procedure in a single 2000F Service Loop. Multiple procedures may be requested by submitting multiple 2000F Service Loops with each loop containing one procedure code. By submitting multiple procedures in this manner, each procedure code submitted will receive a separate response of either approved, pend or denied and certification number. The following example is the correct way to submit multiple procedures: ST*278*1220~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*860813232~ HL*2*1*21*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ PER*IC*LUCY MARKOV*TE*6026645246~ HL*3*2*22*1~ HI*BK:959:D8:20030915*BF:787:D8:20030915~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ HL*5*4*SS*0~ TRN*1*789789ABV*1860813232*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97001:D8:20030915::2~ (Note: 1 st Procedure) HL*6*4*SS*0~ TRN*1*10954*1860813233*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97002:D8:20030815~ (Note: 2 nd Procedure) HL*7*4*SS*0~ TRN*1*10955*1860813234*APIPA~ 278 Comp Guide_v1 17 10/10/03
UM*HS*I*AF*05:B*****Y~ HI*BO:97003:D8:20030915::3~ (Note: 3 rd Procedure) HL*8*4*SS*0~ TRN*1*10956*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97004:D8:20030916::2~ (Note: 4 th Procedure) HL*9*4*SS*0~ TRN*1*10957*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97005:D8:20030919::1~ (Note: 5 th Procedure) HL*10*4*SS*0~ TRN*1*10958*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97006:D8:20030917::2~ (Note: 6 th Procedure) HL*11*4*SS*0~ TRN*1*10959*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:35472:D8:20030916::6~ (Note: 7 th Procedure) HL*12*4*SS*0~ TRN*1*10960*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:63091:D8:20030915::1~ (Note: 8 th Procedure) HL*13*4*SS*0~ TRN*1*10961*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:64613:D8:20030920::3~ (Note: 9 th Procedure) HL*14*4*SS*0~ TRN*1*10962*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97010:D8:20030917::1~ (Note: 10 th Procedure) HL*15*4*SS*0~ TRN*1*10963*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:35472:D8:20030921::2~ (Note: 11 th Procedure) 278 Comp Guide_v1 18 10/10/03
HL*16*4*SS*0~ TRN*1*10964*1860813234*APIPA~ UM*HS*I*AF*05:B*****Y~ HI*BO:97012:D8:20030922::6~ (Note: 12 th Procedure) MSG*ICU SCRIPT_58 12 PROCEDURE CODES WITH SOME AUTO APPROVAL CODES~ SE*64*1220~ Multiple Procedures Erroneously Submitted This is an example of erroneously submitted multiple procedures: ST*278*1219~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*1P*1*RUBBLE*BARNEY****46*959591000~ REF*N5*004199-0166~ PER*IC*LUCY MARKOV*TE*6026645246~ HL*3*2*22*1~ HI*BK:V735~ NM1*IL*1*FLINTSTONE*FRED****MI*99999999-01~ HL*4*3*19*1~ NM1*SJ*1*RUBBLE*BARNEY****46*959591002~ REF*N5*004199-0162~ HL*5*4*SS*0~ TRN*1*10134*1860813232*APIPA~ UM*SC*I*3*11:B*****Y~ HI*BO:26320:D8:20031001*BO:99205:D8:20031001*BO:20690:D8:20031001~ (Note: This transaction will be rejected if multiple procedures are submitted in this format See correct way to submit above.) MSG*SCRIPT_57 MULTIPLE PROCEDURES ERRONEOUSLY SUBMITTED~ SE*20*1219~ 278 Comp Guide_v1 19 10/10/03
278 Scenario #3 EXTENSIONS Initial Submission for a Procedure The first scenario below will show an Initial transaction being submitted for a procedure code. The next scenario will show the initial transaction with a quantity extension. The Initial Transaction submitted is requesting a quantity of 6. ST*278*1217~ BHT*0078*13*A12345*19980908*1101~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*1P*1*RUBBLE*BARNEY****24*959590100~ REF*N5*005181-0040~ HL*3*2*22*1~ HI*BK:1629:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSPITAL*****24*959590010~ REF*N7*004316-0001~ PER*IC**TE*4029993456~ HL*5*4*SS*0~ TRN*1*SSS3333*9012345678~ UM*HS*I*78*13:A*****Y~ HI*BO:Q0084:D8:20031001::6~ (Note: Initial request for Qty of 6. ) MSG*SCRIPT22_BUSINESS~ SE*20*1217~ 278 Comp Guide_v1 20 10/10/03
Extension of the Initial Transaction for a Procedure Code Below is an example of an extension of the original request (above) to a quantity of 11. To extend it, request a quantity of 5. NOTE: The Certification number assigned to the procedure code is required to perform an extension in order to locate the correct transaction in CarePlanner. ST*278*1202~ BHT*0078*13*A12345*19980908*1101~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*1P*1*RUBBLE*BARNEY****24*959590100~ REF*N5*005181-0040~ HL*3*2*22*1~ HI*BK:1629:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSPITAL*****24*959590010~ REF*N7*004316-0001~ PER*IC**TE*4029993456~ HL*5*4*SS*0~ TRN*1*SSS3333*9012345678~ UM*HS*4*78*13:A*****Y~ (Note: Must use Certification Type Code 4 for an Extension. ) REF*BB*032380049S001001~ (Note: Certification number is required on an Extension.) HI*BO:Q0084:D8:20031001::5~ (Note: Extend the request to 11 by requesting a quantity of 5. ) MSG*SCRIPT_10 EXTENSION OF SCRIPT22_BUSINESS Extend procedure code from qty of 6 to 11~ SE*21*1202~ 278 Comp Guide_v1 21 10/10/03
EXTENSIONS Initial LOS (Length of Stay) Request The first scenario below will show an Initial transaction being submitted for a LOS (Length of Stay) for an inpatient. The scenario below this will show the initial transaction with a request to extend the number of days. The Initial Transaction submitted is requesting an inpatient stay of 5 days. ST*278*1219~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*860813232~ HL*2*1*21*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ PER*IC*LUCY MARKOV*TE*6026645246~ HL*3*2*22*1~ HI*BJ:959:D8:20031015*BF:787:D8:20031015~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ HL*5*4*SS*0~ TRN*1*789789ABV*1860813232*APIPA~ UM*AR*I*2*21:B*****Y~ DTP*435*D8*20031015~ HSD*DY*5~ (Note: Initial Request is for 5 Days. The extension below for 3 days will extend the LOS to 8 days.) CL1*1*1~ MSG*SCRIPT26_BUSINESS~ SE*32*1219~ 278 Comp Guide_v1 22 10/10/03
Extension for Initial LOS Request This scenario is requesting to extend the number of days from 5 (above) to a total of 8 days. To do this, the extension request must show the number of days in the extension to be 3. ST*278*1219~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*860813232~ HL*2*1*21*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ PER*IC*LUCY MARKOV*TE*6026645246~ HL*3*2*22*1~ HI*BJ:959:D8:20031015*BF:787:D8:20031015~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE MEMORIAL MED CTR*****24*959591000~ REF*N7*003597-0001~ HL*5*4*SS*0~ TRN*1*789789ABV*1860813232*APIPA~ UM*AR*4*2*21:B*****Y~ (Note: Must use Certification Type Code 4 for an Extension. ) REF*BB*032380049S001001~ (Note: Certification Number is required for Extensions.) DTP*435*D8*20031015~ HSD*DY*3~ (Note: This is the number of days you want to extend for the LOS.) CL1*1*1~ MSG*This is an extension of a LOS~ SE*32*1219~ 278 Comp Guide_v1 23 10/10/03
EXTENSIONS Initial Request for LOS and Multiple Procedures ST*278*1201~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*I*2*11:A*****Y~ DTP*435*D8*20031001~ HSD*DY*5~ (Note: Initial request for a 5 days LOS.) CL1*1*1~ MSG*SCRIPT39_BUSINESS INITIAL LOS AND MULTIPLE PROCEDURES~ HL*6*4*SS*0~ TRN*1*11111111*9512367879~ UM*AR*I*2*11:A*****Y~ DTP*435*D8*20031001~ HI*BO:27130:D8:20031001~ (Note: Initial request for a Procedure.) CL1*1*1~ HL*7*4*SS*0~ TRN*1*11111111*9512367879~ UM*AR*I*2*11:A*****Y~ DTP*435*D8*20031001~ 278 Comp Guide_v1 24 10/10/03
HI*BO:99500:D8:20031001~ CL1*1*1~ SE*34*1201~ (Note: Initial request for the 2 nd Procedure.) Extension of LOS and Multiple Procedures (Above) Please note when an Extension is requested for services that have multiple transactions, and you want to extend each transaction, they must be submitted separately as shown below. If not, then CarePlanner will reject the transaction. See above in the original transaction how all three were initially sent and compare below with the way each must be extended. If only one service needs to be extended, then only submit the service you wish to extend. NOTE: The Certification number is required for each transaction to perform an Extension. ST*278*1201~ (Note: This is the 1 st ST that has the LOS Extension.) BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*4*2*11:A*****Y~ (Note: Must use Certification Type Code 4 for an Extension. ) REF*BB*032380023L001001~ (Note: Certification Number is required for an Extension.) DTP*435*D8*20031001~ HSD*DY*5~ (Note: The Initial request above was for 5 days. The Extension is for 3 more days for a total LOS of 8 days.) CL1*1*1~ SE*22*1201~ ST*278*1202~ (Note: This is the 2 nd ST that has the procedure code extension.) BHT*0078*13*A12345*19980908*1102~ 278 Comp Guide_v1 25 10/10/03
HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*4*2*11:A*****Y~ (Note: Must use Certification Type Code 4 for an Extension. ) REF*BB*032380023S001001~ (Note: Certification Number is required for an Extension.) HI*BO:27130:D8:20031001~ (Note: This is the date that has been extended from 10/1 to 10/5.) SE*20*1202~ ST*278*1203~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ 278 Comp Guide_v1 26 10/10/03
UM*AR*4*2*11:A*****Y~ REF*BB*032380023S002001~ HI*BO:99500:D8:20031001~ SE*20*1203~ (Note: Must use Certification Type Code 4 for an Extension. ) (Note: Certification Number is required for an Extension.) (Note: This would be the Extension for the 2 nd Procedure.) 278 Comp Guide_v1 27 10/10/03
278 Scenario #4 APPEALS Initial Submission This is an example of an initial submission of an Inpatient request for LOS (Length of Stay) and a procedure code. Listed below is an example of this same transaction being appealed. ST*278*1201~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE MEDICAL CENTER*****46*959591000~ REF*1J*004327-0001~ HL*3*2*22*1~ HI*BJ:57510:D8:20030711~ NM1*IL*1*FLINTSTONE*FRED****MI*3804375-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE MEDICAL CENTER*****46*959591000~ REF*1J*004327-0001~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*55555555*9512367879~ UM*AR*I*2*11:A**03***Y~ DTP*435*D8*20030711~ HSD*DY*2~ (Note: Initial request for a 2 day LOS.) CL1*1*1~ MSG*ICU SCRIPT1_BUSINESS~ HL*6*4*SS*0~ TRN*1*55555556*9512367879~ UM*AR*I*2*11:A**03***Y~ DTP*435*D8*20030711~ HI*BO:47600:D8:20030711~ (Note: Initial request for a Procedure.) CL1*1*1~ SE*28*1201~ Appeal of the Initial Transaction Submitted 278 Comp Guide_v1 28 10/10/03
This is an example of submitting an Appeal for the above transaction. NOTE: The Certification number is required for each transaction appealed. ST*278*1204~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE MEDICAL CENTER*****46*959591000~ REF*1J*004327-0001~ HL*3*2*22*1~ HI*BJ:57510:D8:20031011~ NM1*IL*1*FLINTSTONE*FRED****MI*3804375-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE MEDICAL CENTER*****46*959591000~ REF*1J*004327-0001~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*55555555*9512367879~ UM*AR*1*2*11:A**U***Y~ (Note: Must use Certification Type Code 1 or 2 for an Appeal. ) REF*BB*032380071L001001~ (Note: Certification Number is required for an Appeal.) DTP*435*D8*20031011~ HSD*DY*2~ (Note: # of days LOS for the Appeal.) CL1*1*1~ MSG*ICU SCRIPT37 APPEALS URGENT~ HL*6*4*SS*0~ TRN*1*55555556*9512367879~ UM*AR*1*2*11:A**U***Y~ REF*BB*032380071S001001~ (Note: Certification Number is required for an Appeal.) DTP*435*D8*20031011~ HI*BO:47600:D8:20031011~ (Note: Procedure Code Appeal.) CL1*1*1~ SE*30*1204~ Cancellation 278 Comp Guide_v1 29 10/10/03
Initial Submission The purpose of a Cancel Transaction is to Void the original request in CarePlanner. This is a sample of an Initial request for a 5 day LOS and two procedure codes. ST*278*1201~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*118986-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*I*2*11:A*****Y~ DTP*435*D8*20031001~ HSD*DY*5~ (Note: Initial Transaction for LOS of 5 days.) CL1*1*1~ MSG*REH CANCEL SCRIPT39_BUSINESS CHANGED DX QUALIFER CODE FROM BJ TO BK TO SEE IF IT WORKS THIS SHOULD VOID THE PROCEDURE CODES~ HL*6*4*SS*0~ TRN*1*11111111*9512367879~ UM*AR*I*2*11:A*****Y~ DTP*435*D8*20031001~ HI*BO:27130:D8:20031001~ (Note: Initial Transaction for 1 st Procedure.) CL1*1*1~ HL*7*4*SS*0~ TRN*1*11111111*9512367879~ UM*AR*I*2*11:A*****Y~ 278 Comp Guide_v1 30 10/10/03
DTP*435*D8*20031001~ HI*BO:99500:D8:20031001~ CL1*1*1~ SE*37*1201~ (Note: Initial Transaction for 2 nd Procedure.) Cancellation of the Original Submission Above Please note when a Cancel request is submitted for a record that has multiple transactions, each cancel transaction must be sent separately as shown below. See above in the original transaction how all three were initially sent and compare below with the way each must be cancelled. This will void all of the transactions originally sent to CarePlanner. Again, the Certification number is required for each separate transaction to perform a Cancel. ST*278*1201~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*118986-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*3*2*11:A*****Y~ (Note: Certification Type Code 3 is required for Cancel.) REF*BB*032380023L001001~ (Note: Certification Number is Required for Cancel Transaction.) DTP*435*D8*20031001~ HSD*DY*5~ (Note: The Initial # of days request for LOS is required for Cancel.) CL1*1*1~ SE*22*1201~ ST*278*1202~ BHT*0078*13*A12345*19980908*1102~ 278 Comp Guide_v1 31 10/10/03
HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*118986-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ UM*AR*3*2*11:A*****Y~ (Note: Certification Type Code 3 is required for Cancel.) REF*BB*032380023S001001~ (Note: Certification Number is Required for Cancel Transaction.) HI*BO:27130:D8:20031001~ (Note: 1 st Procedure Cancel) SE*20*1202~ ST*278*1203~ BHT*0078*13*A12345*19980908*1102~ HL*1**20*1~ NM1*X3*2*PACIFICARE*****46*789312~ HL*2*1*21*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ HL*3*2*22*1~ HI*BK:7150:D8:20031001~ NM1*IL*1*FLINTSTONE*FRED****MI*9999999-01~ HL*4*3*19*1~ NM1*FA*2*RUBBLE COMMUNITY HOSP*****46*959591000~ REF*1J*006350-0003~ PER*IC**TE*7142268094~ HL*5*4*SS*0~ TRN*1*121212121*9512367879~ 278 Comp Guide_v1 32 10/10/03
UM*AR*3*2*11:A*****Y~ REF*BB*032380023S002001~ HI*BO:99500:D8:20031001~ SE*20*1203~ (Note: Certification Type Code 3 is required for Cancel.) (Note: Certification Number is Required for Cancel Transaction.) (Note: 2 nd Procedure Cancel) 278 Comp Guide_v1 33 10/10/03
Appendix B Testing Requirements Testing Requirements EDI Trading Partner Testing PacifiCare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP) Testing Sub-Workgroups recommendations on the types of testing that need to occur in order to remain in line with the health care industry s testing recommendations. The testing white paper may be found on the WEDI SNIP Web site. The paper suggests that types 1, 2 and 4 testing should be successfully completed. Type 3 testing applies to remittance advice balancing and is addressed in the X12N 835 instructions. Initially, the types of testing that PacifiCare strongly recommends for the 278 Transaction Set include:! Type 1: EDI syntax integrity testing Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity of the EDI submission.! Type 2: HIPAA syntactical requirement testing Testing for HIPAA Implementation Guidespecific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or table. Third-Party Certification Systems and Services (TPCSS) TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their HIPAA transactions. PacifiCare requests that Trading Partners test with a TPCSS and provide evidence of such testing. EDI submitters that have tested their 278 Transaction Sets with a certification system may provide a certificate of compliance. The certificate should specify the different types of testing passed, or provide us with a certification website that indicates you have successfully passed certain types of certification testing. A sample of some of the current certification and testing services available today are provided in the WEDI SNIP Testing and Certification White Paper found on the WEDI SNIP Web site. PacifiCare will collect evidence of the Third-Party Certification during the Trading Partner Setup process. 278 Comp Guide_v1 34 10/10/03
APPENDIX C Crosswalk Tables Crosswalk Table 56 CarePlanner Treatment Setting Codes Facility Code Values UM 04-1/1331 A NUBC Codes UM04-2/1332 HIPAA Code HIPAA Code Description PacifiCare CarePlanner Code 11 HOSPITAL INPATIENT (Including Medicare Part A) I INPATIENT 12 HOSPITAL I/P (MEDICARE PART B ONLY) I INPATIENT 13 HOSPITAL OUTPATIENT O OUTPATIENT 14 HOSPITAL OTHER O OUTPATIENT 15 HOSPITAL INTERMEDIATE CARE - LEVEL 1 I INPATIENT 16 HOSPITAL INTERMEDIATE CARE - LEVEL 2 I INPATIENT PacifiCare CarePlanner Code Description 17 HOSPITAL SUBACUTE I/P (REVENUE CODE 19X REQUIRED WHEN THIS BILL TYPE IS USED, HOWEVER 19X MAY BE USED WITH OTHER TYPES OF BILLS) I INPATIENT 18 SWING BEDS I INPATIENT 21 SKILLED NURSING FACILITY - I/P (INCLUDING MEDICARE PART A) S SNF - FREESTANDING 22 SKILLED NURSING FACILITY - INPATIENT (MEDICARE PART B ONLY) S SNF - FREESTANDING 23 SKILLED NURSING FACILITY - OUTPATIENT O OUTPATIENT 24 SILLED NURSING FACILITY OTHER - (FOR HOSITAL REFERENCED DIAGNOSTIC SERVICES, OR HOME HEALTH NOT UNDER A PLAN OF TX) O OUTPATIENT 25 SKILLED NURSING FACILITY-INTERMEDIATE CARE - LEVEL 1 S SNF - FREESTANDING 26 SKILLED NURSING FACILITY S SNF - FREESTANDING 27 SKILLED NURSING FACILITY-SUBACUTE INPATIENT (REVENUE CODE 19X REQUIRED WHEN THIS BILL TYPE IS USED) S SNF - FREESTANDING 28 SKILLED NURSING FACILITY - SWING BEDS S SNF - FREESTANDING 278 Comp Guide_v1 35 10/10/03
HIPAA Code HIPAA Code Description PacifiCare CarePlanner Code 34 HOME HEALTH - OTHER H HOME 61 INTERMEDIATE CARE -INPATIENT (INCLUDING MEDICARE PART A) I INPATIENT 62 INTERMEDIATE CARE - INPATIENT (MEDICARE PART B ONLY) I INPATIENT 63 INTERMEDIATE CARE - OUTPATIENT O OUTPATIENT PacifiCare CarePlanner Code Description 64 INTERMEDIATE CARE - OTHER (FOR HOSPITAL REFERENCED DIAGNOSTIC SERVICES, OR HOME HEALTH NOT UNDER A PLAN OF TX) O OUTPATIENT 65 INTERMEDIATE CARE - LEVEL 1 I INPATIENT 66 INTERMEDIATE CARE - LEVEL 2 I INPATIENT 67 INTERMEDIATE CARE -SUBACTURE INPATIENT (REVENUE CODE 19X REQUIRED WHEN THIS BILL TYPE IS USED, HOWEVER 19X MAY BE USED WITH OTHER TYPES OF BILLS) I INPATIENT 68 INTERMEDIATE CARE - SWING BEDS I INPATIENT 71 CLINIC - RURAL HEALTH O OUTPATIENT 72 CLINIC - HOSPITAL BASED OR INDEPENDENT RENAL DIALYSIS CENTER O OUTPATIENT 73 CLINIC - FREESTANDING P PROVIDER OFFICE 74 CLINIC - OUTPATIENT O OUTPATIENT 75 CLINIC - COMPREHENSIVE OUTPATIENT REHABILITATION FACILITIES (CORF'S) O OUTPATIENT 76 CLINIC - COMMUNITY MENTAL HEALTH CENTER MH MENTAL HEALTH - PARTIAL HOSPITALIZATION 79 CLINIC - OTHER O OUTPATIENT 81 SPECIAL FACILITY - HOSPICE I INPATIENT 82 SPECIAL FACILITY - HOSPICE (HOSPTIAL BASED) I INPATIENT 83 SPECIAL FACILITY - AMBULATORY SURGERY CENTER O OUTPATIENT 84 SPECIAL FACILITY - FREE STANDING BIRTH CENTER O OUTPATIENT 85 SPECIAL FACILITY - CRITICAL ACCESS HOSPITAL I INPATIENT 86 SPECIAL FACILITY - RESIDENTIAL FACILITY H HOME 89 SPECIAL FACILITY - OTHER O OUTPATIENT 278 Comp Guide_v1 36 10/10/03