Medicare Part B of Florida 837 Version 4010 A1 Companion Document

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicare, and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health and Human Services. The X12N 837 implementation guides have been established as the standards of compliance for submission of claims for all services, supplies, equipment, and health care other than retail pharmacy prescription drug claims. The implementation guides for each X12 transaction adopted as a HIPAA standard are available electronically at http://www.wpc-edi.com

The following information is intended to serve only as a companion document to the HIPAA X12N 837 professional claim implementation guide. The use of this document is solely for the purpose of clarification.

The information describes specific requirements to be used for processing data in the Multi Carrier System (MCS) of First Coast Service Options, Inc. (FCSO), Contractor number 00590. The information in this document is subject to change. Changes will be communicated in the standard Medicare B EDI news bulletin and on the FCSO Web site at http://www.fcso.com

. This companion document supplements, but does not contradict any requirements in the X12N 837 Professional implementation guide.

Below is a listing of Medicare-specific guidelines related to the HIPAA 4010A1 837 Transaction

• The maximum number of characters to be submitted in the dollar amount field is seven characters. Claims in excess of 99,999.99 will be rejected.

• Claims that contain percentage amounts with values in excess of 99.99 will be rejected.

• Claims that contain percentage amounts cannot exceed two positions to the left or the right of the decimal. Percent amounts that exceed their defined size limit will be rejected.

• First Coast Service Options, Inc. will convert all lower case characters submitted on an inbound 837 file to upper case when sending data to the Medicare processing system. Consequently, data later submitted for coordination of benefits will be submitted in upper case.

• Only loops, segments, and data elements valid for the HIPAA Professional Implementation Guides will be translated. Submitting data not valid based on the Implementation Guide will cause files to be rejected.

• You must submit incoming 837 claim data using the basic character set as defined in Appendix A of the 837 Professional Implementation Guide. In addition to the basic character set, you may choose to submit lower case characters and the '@' symbol from the extended character set. Any other characters submitted from the extended character set may cause the interchange (transmission) to be rejected at the carrier translator. Use of the tilde (~), asterisk (*) or greater than sign (>) other than as delimiters will cause the file to reject.

• The National Provider Identifier (NPI) must be submitted in the NM109 segment (NM108=XX).

• Medicare does not require taxonomy codes be submitted in order to adjudicate claims, but will accept the taxonomy code, if submitted. However, taxonomy codes that are submitted must be valid against the taxonomy code set published at http://www.wpc-edi.com/codes/taxonomy

. Claims submitted with invalid taxonomy codes will be rejected.

• All dates that are submitted on an incoming 837 claim transaction must be valid calendar dates in the appropriate format based on the respective qualifier. Failure to submit a valid calendar date will result in rejection of the claim or the applicable interchange (transmission).

• Compression of files using PKZIP is supported for transmissions between the submitter and First Coast Service Options, Inc.

• Only valid qualifiers for Medicare must be submitted on incoming 837 claim transactions. Any qualifiers submitted for Medicare processing that are not defined for use in Medicare billing may cause the claim or the transaction to be rejected.

• You may send up to four modifiers; however, the last two modifiers will not be considered. The First Coast Service Options, Inc. processing system will only use the first two modifiers for adjudication and payment determination of claims.

• First Coast Service Options, Inc. will only accept claims for one line of business per transaction. Claims submitted for multiple lines of business within one ST-SE (Transaction Set) will cause the transaction to be rejected.

• First Coast Service Options, Inc. will reject an interchange (transmission) that is not submitted with unique values in the ST02 (Transaction Set Control Number) elements.

• Transaction Set Purpose Code (BHT02) must equal '00' (ORIGINAL).

• Claim or Encounter Indicator (BHT06) must equal 'CH' (CHARGEABLE).

• First Coast Service Options, Inc. will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission.

• The subscriber hierarchical level (HL segment) must be in order from one, by one (+1) and must be numeric.

• For Medicare, the subscriber is always the same as the patient (SBR02=18, SBR09=MB). The Patient Hierarchical Level (2000C loop) is not used.

• Do not use Credit/Debit card information to bill Medicare (2300 loop, AMT01=MA and 2010BD loop).

• Negative values submitted in CLM02 will not be processed and will result in the claim being rejected.

• Total submitted charges (CLM02) must equal the sum of the line item charge amounts (SV102).

• The only valid value for CLM05-3 is '1' (ORIGINAL). Claims with a value other than ‘1’ may be rejected.

• Data submitted in CLM20 will not be used for processing.

• Any data submitted in the PWK (Paperwork) segment will not be considered for processing.

• Negative values submitted in the following fields will not be processed and will result in the claim being rejected: AMT02 (2300 Loop Patient Amount Paid).

• Negative values submitted in the following fields will not be processed and will result in the claim being rejected: AMT02 (2300 & 2400 Loops Total Purchased Service Amount).

• Peer Review Organization (PRO) information should be submitted at the header claim level (Loop 2300). PRO information submitted at the detail line level (Loop 2400) will be ignored.

• Negative values submitted in the following fields may not be processed and may result in the claim being rejected: CR102, CR106 (2300 & 2400 loop Ambulance Transport Information).

• Diagnosis codes have a maximum size of five (5). Medicare does not accept decimal points in diagnosis codes.

• Effective July 2004, all diagnosis codes submitted on a claim must be valid codes per the qualified code source. Claims that contain invalid diagnosis codes, pointed to or not, will be rejected.

• You may send up to eight diagnosis codes per claim. If diagnosis codes are submitted, you must point to the primary diagnosis for each service line.

• Negative values submitted in the following fields may not be processed and may result in the claim being rejected: AMT02 (2320 Loop Coordination of Benefits Amounts).

• Negative values submitted in the following fields may not be processed and may result in the claim being rejected: SV102 (2400 Loop Line Item Charge Amounts).

• The max value for anesthesia minutes (qualifiers MJ) cannot exceed 4 bytes numeric. Claims for anesthesia services that exceed this value will be rejected. (SV104).

• Anesthesia claims must be submitted with minutes (qualifiers MJ). Claims for anesthesia services that do not contain minutes may be rejected. (SV104)

• The max value for units (qualifier UN) cannot exceed three bytes numeric with one decimal place. Claims for medical services that exceed this value will be rejected. (SV104).

• SV104 (Service unit counts) (units or minutes) cannot exceed 999.9

• Negative values submitted in the following fields may not be processed and may result in the claim being rejected. (SV104).

• Purchased diagnostic tests (PDT) require that the purchased amounts be submitted at the detail line level (Loop 2400). Claims for PDT services that are submitted without the PS1 segment data at the 2400 loop may be rejected.

• Negative values submitted in the following fields will not be processed and will result in the claim being rejected: (PS102).

• We suggest retrieval of the ANSI 997 functional acknowledgment files on or before the first business day after the claim file is submitted, but no later than five days after the file submission.

• First Coast Service Options, Inc. will return the version of the 837 inbound transaction in GS08 (Version/Release/Industry Identifier Code) of the 997.

Production

First Coast Service Options, Inc. will no longer reject an interchange (transmission) with more than 5,000 CLM segments (claims) submitted per transaction.

Testing

Vendors, senders, billing services or clearinghouses should request a testing appointment as soon as possible. Appointment slots will be assigned on a first come basis. To schedule an appointment, call (904) 354-5977 option 4. If a test transmission is received from submitter that does not have an appointment, there is no guarantee the file will be reviewed.

If an EDI submitter is using a vendor, clearinghouse, or billing service to generate a certain transaction and that entity has passed testing requirements for a specific transaction and is using the same program to generate the translation for all of their clients, then all clients of the vendor, clearinghouse, or billing service will not be required to test prior to acceptance of production submission of the HIPAA claim transaction. If you support multiple software products, each product will require testing.

It is the responsibility of the vendor, clearinghouse or billing service to provide Medicare a listing of their clients to be migrated.

All NEW EDI submitters are required to test. If your support vendor/trading partner is considered an approved vendor or established trading partner, you do not have to test. You will need to notify Medicare EDI when you are prepared to send production files as all new submitters are configured to test.

Submitter/Receiver testing of HIPAA transactions is evaluated at WEDI levels 1 and 2. Submitters’ claims must pass 100% of the standard syntax edits and at least 95% of the IG level edits. FCSO will not test on any pre-HIPAA format except for legacy eligibility transactions pending end of contingency.

To schedule an EDI submitter test, please call 904-354-5977 option 4.

Below are specifications necessary for creating and transmitting your file.

Test File

You must submit a minimum of 25 claims that are representative of all types of bills you currently send to Medicare Part B. We ask that you only send us positive test files, which contain claims you believe should process and pay. Note: this file will only be processed as a test. No claims will be paid.

Delimiters

The Functional Acknowledgment report (997) will be returned to you using the delimiters specified within the 837. If you would like the 997 to be returned with other delimiters, you will need to notify us of those override delimiters before testing. Note: if you use the tilde (~) as a segment delimiter your 997 will be returned to you as one string, “unwrapped”.

Enveloping

Enveloping information must be as follows:

ELEMENT	CONTENT
ISA 05 & 07	ZZ
ISA 06	Your Mailbox Number
ISA 08	592015694
ISA 15	T *
GS 02	Your Sender Number
GS 03	MEDBCLM00590
GS 08	004010X098A1
REF 02	004010X098A1
NM109 (1000A Loop)	Your Sender Number
NM109 (1000B Loop)	00590

* Note: Once you are given the approval to begin submitting production version 4010A1, this indicator will change to “P.”

Commands

The commands used to submit the ANSI X12 files and obtain the acknowledgments are slightly different than those that are used to submit and obtain acknowledgments for National Standard Format. The appropriate command instructions can be found in our publication Guide To Gateway, which is available on our Web site at http://www.fcso.com

Reports

If your test file contains incorrect enveloping information (ISA, GS, ST, SE, GE, and IEA segments) a TA1 will be returned to you. If you need assistance reading your TA1 please contact Medicare EDI at 904-354-5977 option 4.

If your enveloping information is correct, your file will create a Functional Acknowledgment (997) report. This report, sent to your mailbox for retrieval, will tell you if your file has been accepted under X12 Standard. Standard requirements can be found in the 4010A1 Implementation Guide (IG) under the STANDARD heading for each segment. (The IG may be downloaded from http://www.wpc-edi.com

If your file passes the Standard, it is then reviewed for X12 Implementation Guide requirements. X12 IG requirements can be found in the 4010A1 IG under the IMPLEMENTATION heading for each segment and in the body of the segment information. If your file fails any IG requirements, you will be notified via e-mail of the test results. Claims failing IG requirements will need to be corrected and resubmitted for review.

If your file passes both Standard and IG edits, the claims are then reviewed for data accuracy and potential billing errors. Medicare will contact you with your test results via fax or e-mail within 3 business days.

If you have additional questions, please contact Medicare EDI testing and Format Support at 904-354-5977 option 4.