Kentucky HIPAA HEALTH CARE CLAIM: INSTITUTIONAL Companion 837 Version 1.4 Final
RECORD OF CHANGE VERSION NUMBER DATE REVISED DESCRIPTION OF CHANGE PERSONS INVOLVED 1.0 10/25/02 Creation and first view by DMS Unisys Tim Collins Martha Senn 1.1 03/05/04 Modified the companion guide to reflect 1. The required mapping for certain provider type 2. Other corrections based on post-hipaa requirement 1.2 07/22/04 Update Added new instructions for billing Y1 indicator and KenPAC number. Unisys Tim Collins Martha Senn Laura Kovac 1.3 11/3/04 Inserted SBR02 segment Martha Senn 1.4 4/12/05 Modified the companion guide to reflect 1. Update page 4-5 with PAT statement 2. Insert adjustment segments Martha Senn DMS APPROVED 1/22/03 04/02/04 8/18/04 11/8/04 4/20/05 April 26, 2005 i Record of Change
TABLE OF CONTENTS DESCRIPTION PAGE 1. CONTROL SEGMENT DEFINITIONS FOR KENTUCKY MEDICAID 1-1 2. SEGMENT DEFINITIONS FROM THE IMPLEMENTATION GUIDE 2-1 3. INTRODUCTION TO THE 837 HEALTH CARE CLAIM: INSTITUTIONAL TRANSACTION 3-1 4. 4-1 5. PROGRAM SPECIFIC REQUIRED INFORMATION FOR KY MEDICAID CLAIMS PROCESSING 5-1 6. APPENDIX A CONTACT INFORMATION 6-1 April 26, 2005 ii Table of Contents
1. CONTROL SEGMENT DEFINITIONS FOR KENTUCKY MEDICAID 1.1. X12N EDI CONTROL SEGMENTS ISA Interchange Control Header IEA Interchange Control Trailer GS Functional Group Header GE Functional Group Trailer TA1 Interchange Acknowledgment 1.2. ISA - INTERCHANGE CONTROL HEADER SEGMENT Reference Definition Values ISA01 Authorization 00 Qualifier ISA02 Authorization [space fill] ISA03 Security 00 Qualifier ISA04 Security [space fill] ISA05 Interchange ID Qualifier ZZ ISA06 Interchange Sender ID [Your 10 digit Unisys assigned Trading Partner ID] ISA07 Interchange ID Qualifier ZZ ISA08 Interchange Receiver ID [KYMEDICAID] ISA09 Interchange Date The date format is YYMMDD ISA10 Interchange Time The time format is HHMM ISA11 Interchange Control U Standards Identifier ISA12 Interchange Control 00401 Version Number ISA13 Interchange Control Number ISA14 Acknowledgment Request 1 ISA15 Usage Indicator T= Test Data ISA16 Component Element Separator : 1.3. IEA - INTERCHANGE CONTROL TRAILER Must be identical to the interchange trailer IEA02 (defined by sending Trading Partner) P = Production Data Reference Definition Values IEA01 Number of included Number of included Functional Groups Functional Groups IEA02 Interchange Control Must be identical to the value in ISA13 April 26, 2005 1-1 Control Definitions
Number 1.4. GS FUNCTIONAL GROUP HEADER Reference Definition Values GS01 Functional Identifier HC = Health Care Claim (837) GS02 Application Sender s Must be identical to the value in ISA06 GS03 Application Receiver s KYMEDICAID GS04 Date The date format is CCYYMMDD GS05 Time The time format is HHMM GS06 Group Control Number Assigned and maintained by the sender GS07 Responsible Agency X GS08 Version/Release/Industry Identifier 004010X096A1 1.5. GE FUNCTIONAL GROUP TRAILER Reference Definition Values GE01 Number of Transaction Number of Transaction Sets Included Sets Included GE02 Group Control Number Must be identical to the value in GS06 1.6. VALID DELIMITERS FOR KENTUCKY MEDICAID EDI Definition ASCII Decimal Hexadecimal Separator ~ 126 7E Element Separator * 42 2A Compound Element Separator : 58 3A Transmission Constraints Only one interchange per transmission Only one transaction type per interchange April 26, 2005 1-2 Control Definitions
2. SEGMENT DEFINITIONS FROM THE IMPLEMENTATION GUIDE ISA - Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record. IEA - Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record. GS Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record. GE Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record. ST Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record. SE Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments (including the beginning (ST) and ending (SE) segments). This segment may be thought of traditionally as the claim trailer record. April 26, 2005 2-1 Definitions from the
3. INTRODUCTION TO THE 837 HEALTH CARE CLAIM: INSTITUTIONAL TRANSACTION The 837 transaction under HIPAA is the standard electronic exchange of information between two parties to carry out financial activities related to health care. The health care claim or equivalent encounter information transaction is the transmission of either of the following: A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care. The 837 Health Care Claim transaction set can be used to submit health care claim billing information, encounter information, or both. It can be sent from providers of health care services to payers, either directly or via intermediary billers and claims clearinghouses. It can also be used to transmit health care claims and billing payment information between payers with different payment responsibilities where coordination of benefits are required or between payers and regulatory agencies to monitor the rendering, billing, and/or payment of health care services within a specific health care/insurance industry segment. For purposes of this standard, providers of health care products or services may include entities such as physicians, hospitals and other medical facilities or suppliers, dentists and pharmacies and entities providing medical information to meet regulatory requirements. The payer refers to a third party entity that pays claims or administers the insurance benefit. A regulatory agency is an entity responsible, by law or rule, for administering and monitoring a statutory benefits program or a specific health care/insurance industry segment. Health Care Claim: Institutional ASC X12N 837(004010X096) May 2000 Addenda Health Care Claim: Institutional ASC X12N 837(004010X096A1) October 2002 April 26, 2005 3-1 Introduction to the 837I Transaction
FIELD DEFINITIONS COLUMN A The current field as identified by the Institutional electronic format claims specifications and record layout. Any new fields are indicated. B The current descriptions for the fields used for Kentucky Medicaid electronic format. C The name of the loop as documented in the appropriate HIPAA 837. D A loop ID number used to identify a group of segments that are collectively repeated in a serial fashion up to a specified maximum number of times as documented in the appropriate 837. E The HIPAA field position number and segment number as specified in the appropriate 837. F The data element name and page number as indicated in the appropriate 837 HIPAA. G The Values and further describe the appropriate 837 field data that Kentucky Medicaid will send. Note: The valid values in bold are the values KY Medicaid expect to receive in the transmission. April 26, 2005 3-2 Introduction to the 837I Transaction
4. on 10/16/03 Current Medicaid Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G New Field Beginning of Hierarchical Transaction 010-BHT02 Transaction Set Purpose Pg 58 00 Original New Field Beginning of Hierarchical Transaction 010-BHT06 Transaction Type Pg 59 New Field Submitter Name 1000A 020-NM109 Identification Pg 63 New Field Submitter Name 1000A 045-PER03 Communication Number Qualifier Pg 65 New Field Receiver Name 1000B 020-NM103 Name Last or Organization Name Pg 68 New Field Receiver Name 1000B 020-NM109 Identification Pg 68 CH Chargeable Assigned EDI Trading Partner ID TE Telephone (Telephone number required as a minimum) KYMEDICAID KYMEDICAID April 26. 2005 4-1
Pay-To Provider : (Required for KY Medicaid) Alternate Location 1: Pay-To Provider is the same as the Billing Provider Page 76 Loop 2010AA Current Medicaid on 10/16/03 Record Type 10 Paper form 51 Record Type 10 Paper form 51 Current Medicaid Medicaid Provider Number Loop Name Loop ID HIPAA Field Billing Provider Name Billing Provider Name HIPAA Data Element Name/Page Number from 2010AA 035-REF01 Reference Identification Qualifier Pg 83 2010AA 035-REF02 Reference Identification Pg 84 1D Medicaid Provider Number 10 digit KY Medicaid provider number April 26. 2005 4-2
Attending Provider Location Attending Provider information is required for Inpatient Services This information may occur in Loop 2310A page 321 at the Claim level. Alternate Location 1: Page 321 Loop 2310A Claim Level Current Medicaid Implementatio n on 10/16/03 Current Medicaid Loop Name New Field Attending Physician Name New Field Attending Physician Name Record Type 80 Paper form 82 Attending Physician Number Attending Physician Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from 2310A 250-NM102 Entity Type Qualifier Pg 322 2310A 271-REF01 Reference Identification Qualifier Pg 326 2310A 271-REF02 Reference Identification Pg 327 1 Person 1G Provider UPIN number OB State License Number Attending Physician Identifier April 26. 2005 4-3
KenPAC Provider KenPAC Provider information should be billed in this loop when required for Inpatient/Outpatient Services. Page 335 Loop 2310C - Claim Level Current Medicaid Implementatio n on 10/16/03 Current Medicaid Loop Name New Field Other Provider Name New Field Other Provider Name Record Type 22 Paper form 56 KenPAC Number Other Provider Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from 2310C 250-NM102 Entity Type Qualifier Pg 336 2310C 271-REF01 Reference Identification Qualifier Pg 340 2310C 271-REF02 Reference Identification Pg 341 1 Person 1D Medicaid Provider Number 10 digit Kentucky Provider Number April 26. 2005 4-4
Note: For Kentucky Medicaid, the subscriber is always the same as the patient (SBR02=18, SBR09=MA). Claims containing data in the Patient Hierarchical Level (2000C loop) will not be processed. on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G New Field Subscriber Hierarchical Level 2000B 001-HL04 Hierarchical Child Pg 100 New Field Subscriber Hierarchical Level New Field Subscriber Hierarchical Level 2000B 005-SBR01 Payer Responsibility Sequence Number Pg 102 2000B 005-SBR02 Individual Relationship code Pg 103 0 No Subordinate HL s Refer to for valid values 18 Self subscriber will always be self for KY Medicaid. Record Type 30 Source of payment code Subscriber Hierarchical Level 2000B 005-SBR09 Claim filing Indicator Pg 104 MC Medicaid New Field Subscriber Name 2010BA 015-NM102 Entity Type Qualifier Pg 109 1 Person New Field Subscriber Name 2010BA 015-NM108 Identification Qualifier Pg 110 MI Member Identification Number April 26. 2005 4-5
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G Record Type 30 Paper form Field 58 Subscriber Name 2010BA MAID NUMBER Certificate/Social Security Number Health Insurance Claim/Identification Number (MAID Number) 015-NM109 Identification Patient Primary Identifier Pg 110 New Field Payer Name 2010BC 015-NM103 Name Last or Organization Name Pg 127 New Field Payer Name 2010BC 015-NM108 Identification Qualifier Pg 127 KYMEDICAID PI Payer Identification New Field Payer Name 2010BC 015-NM109 Identification Pg 128 New Field Claim 2300 130-CLM05 Claim Frequency Type Pg 160 KYMEDICAID 7 Adjustment 8 Claim Credit New Field Claim New Field Claim 2300 130-CLM06 Yes/No Condition or Response Pg 160 2300 130-CLM08 Yes/No Condition or Response Pg 160 Y Yes Y Yes April 26. 2005 4-6
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G Record Type 20 Discharge Hour Discharge Hour 2300 135-DTP03 Date Time Period Discharge hour Paper Form 21 Discharge Hour Record Type 20 Paper Form 6 Statement Covers Period Claim Pg 166 2300 135-DTP02 Date Time Period Format Qualifier Pg 167 RD8 Range of Dates From and Through dates of service Record Type 20 Paper form 17(Admission Date) 18 (Admission Hour) Admission /Start Care Date Admission Hour Admission Date/Hour 2300 135-DTP03 Date Time Period Admission Date and Hour Pg 170 Admit Date Admit Hour Record Type 20 Paper form 19 Type of Admission Institutional Claim 2300 140-CL101 Admission Type Pg 171 Record Type 20 Paper form 20 Source of Admission Institutional Claim 2300 140-CL102 Admission Source Pg 172 Record Type 20 Paper form 22 Patient Status Institutional Claim 2300 140-CL103 Patient Status Pg 172 April 26. 2005 4-7
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G New Field Original Reference Number 2300 180-REF01 Reference Identification Qualifier New Field Original Reference Number New Field Prior Authorization or Referral Number Pg 191 2300 180-REF02 Reference Identification Pg 192 2300 180-REF01 Reference Identification Qualifier Pg 198 F8 Original Reference Number Original Transaction Control Number (TCN) G1 Prior Authorization Number Record Type 40 Paper form 63 Treatment Authorization Prior Authorization or Referral Number 2300 180- REF02 Reference Identification Prior Authorization Number Pg 199 Assigned Prior Authorization Number New Field Claim Record Type 41 Paper form 25 26 Home Health providers only Non-covered services Claim 2300 190-NTE01 Note Reference Pg 206 2300 216-CR607 Yes/No Condition or Response Pg 213 UPI Updated Y Medicare Coverage Indicator April 26. 2005 4-8
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G Record Type 70 Other Diagnosis Other Diagnosis 2300 231-HI01-2 Industry Paper form 68-75 Pg 233 Use appropriate Reference New Field Principal Procedure Record Type 70 Paper form 80 Record Type 70 Paper form 80 Principal Procedure Principal Procedure Date Principal Procedure Principal Procedure New Field Other Procedure Record Type 70 Page form 81A-E Other Procedure Other Procedure 2300 231-HI01-1 List Qualifier Pg 242 2300 231-HI01-2 Industry Principal Procedure Pg 243 2300 231-HI01-4 Date Time Period Pg 243 2300 231-HI01-1 List Qualifier Pg 244 2300 231-HI01-2 Industry Procedure Pg 245 BR International Classification of Diseases Clinical Modification (ICD-9- CM) Principal Procedure Principal Procedure BQ International Classification of Diseases Clinical Modification (ICD-9- CM) Procedure Other Procedure April 26. 2005 4-9
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G Record 70 Other Procedure Other Procedure Page form 81A-E Date 2300 231-HI01-4 Date Time Period Procedure Date Pg 245 New Field Claim Quantity 2300 240-QTY01 Quantity Qualifier Pg 306 CA Covered -Actual NA Number of noncovered days New Field Service Facility Name 2310E 271-REF01 Reference Identification Qualifier Pg 357 1J Facility ID Number Paper form 11 Nursing Facility where the Hospice recipient is a resident Service Facility Name 2310E 271-REF02 Reference Identification Pg 358 Nursing Facility Provider Number for Hospice claim use only See Section 5 2a of the Program specific required information for KY Medicaid claims processing Record Type 50 Paper form 44 Accommodation Rates Institutional Service Line 2400 375- SV206 Unit Rate Service Line Rate April 26. 2005 4-10
on 10/16/03 Loop Name Loop ID HIPAA Field HIPAA Data Element Name/Page Number from A B C D E F G Pg 449 Record Type 50 Paper 47-50 Accommodation Non-covered charges Institutional Service Line New Field Service Line Adjustment New Field Service Line Adjustment New Field Service Line Adjustment New Field Service Line Adjustment 2400 375-SV207 Monetary Amount Line Item Denied Charge or Non- Covered Charge Amount Pg 449 2430 545-CAS01 Claim Adjustment Group Pg. 495 2430 545-CAS02 Claim Adjustment Reason Pg 496 2430 545-CAS03 Monetary Amount Adjustment Amount Pg 496 2430 545-CAS04 Quantity Pg 496 CR Correction and Reversals OA Other Adjustments For adjustment reason codes see http://wpc-edi.com April 26. 2005 4-11
5. PROGRAM SPECIFIC REQUIRED INFORMATION FOR KY MEDICAID CLAIMS PROCESSING Companion 837I 1. Hospice providers who bill claims for recipients that reside in a Nursing Facility must bill the required 8-digit KY Medicaid Nursing Facility provider number in the following loop. a. Loop 2310E REF02 segment April 26, 2005 5-1 Companion for 837I Transaction
6. APPENDIX A CONTACT INFORMATION Companion 837I Should you have any questions regarding the electronic format information contained in this document please contact the EDI Department at Unisys (800) 205-4696, Monday Friday 7:30am 6:00pm EST. April 26, 2005 6-1 Contact