Medicare Part B of Florida 276/277 Version 4010A1 Companion Document

The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996(HIPAA-AS) require that Medicare, and all other health insurance payers in the United States, comply with the EDI standards adopted by the Secretary of Health and Human Services for electronic health care transactions. The ANSI X12N 276/277 version 4010A1 Implementation Guide has been established as the standard for the electronic health care claims status request and response transactions. This implementation guide is available electronically at http://www.wpc-edi.com/HIPAA

The following information is intended to serve only as a companion document to the HIPAA-AS ANSI X12N 276/277, version 004010X093A1 Implementation Guide. The use of this document is solely for the purpose of clarification and is not a substitute for review of the relevant Implementation Guide. The Table provided below indicates those segments or data elements in the X12N 276/277 Implementation Guide version 4010A1 that allow for Medicare to specify its business requirements. The information describes specific requirements used by First Coast Service Options, Inc. 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 First Coast Service Options, Inc. web site at http://www.fcso.com

. This companion document supplements, but does not contradict any requirements in the X12N 276/277 version 004010X093A1 Implementation Guide.

Below is a listing of Medicare-specific guidelines related to the HIPAA-AS 4010A1 276/277 FL B Transaction

• Negative values submitted in the following fields will not be processed and will result in rejection of the Claim Status Request:

• Total Claim Charge Amount (2200D Loop, AMT02),

• Line Item Charge Amount (2210D Loop, SVC02),

• Original Units of Service Count (2210D Loop, SVC 07),

• Total Claim Charge Amount (2200E Loop, AMT 02),

• Line Item Charge Amount (2210E Loop, SVC 02),

• Original Units of Service Count (2210E Loop, SVC 07).

• First Coast Service Options, Inc. will process your request for claim status information in batch mode, Central Processing unit to central processing unit (CPU to CPU).

• Upon receipt of your 276, we will generate one or more of the following:

• TA1 for interchange control errors within four hours of receipt of a 276 Request file, or

• 997 to confirm receipt/advise of interchange control/syntax errors within four hours of receipt of a 276 Request file.

• Implementation Guide (IG) Edit Report with identified errors within one business day of receiving a 276 Request file.

• 277 Response within one business day of receiving a valid 276 Request file.

• First Coast Service Options, Inc. will process your 276 as identified in the implementation guide and create a 277 as identified in the implementation guide. At least the minimum response data will be sent.

• The 276 transaction must utilize delimiters as defined in the standard. The delimiters selected must not occur in the transmitted data elements. The delimiters used in a 277 response or in an acknowledgment may not necessarily be the same as the delimiters submitted in the original 276 request transaction.

• The incoming 276 transaction should utilize delimiters from the following list: >, *, ~, ^, |, and: for Medicare B processing. Submitting delimiters not supported within this list will lead to transmission rejection. The delimiters selected must not occur in the transmitted data elements.

• You must submit incoming 276 Claim Status Request data using the basic character set as defined in Appendix A of the 276/277 Implementation Guide. In addition to the basic character set, you may choose to submit a…z (lower case characters), @ (at symbol), ‘_’ (underscore) and ‘ ‘ (space) from the extended character set. Any other characters submitted from the extended character set will 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.

• All alphabetic characters in the 277 transaction will be upper case. If lower case characters are included in the 276 request, they will be converted to upper case for data storage and return processing purposes.

• Multiple functional groups (GS to GE segments) can be sent in one interchange (ISA to IEA segments). Multiple 276’s or 277’s (ST through SE) can be included in a single functional group.

• For Medicare, the subscriber and the patient are the same person. The Dependent Level hierarchical level is never used.

• The maximum number of characters to be submitted in the dollar amount field is seven characters. Claim Status Requests with dollar amounts in excess of 99,999.99 will be rejected.

• The maximum number of SVC segments per TRN in an incoming 276 transaction is 50.

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

• Total submitted charges (AMT02) must equal the sum of the line item charge amounts (SVC02).

• Only loops, segments, and data elements valid for the incoming 276 transaction, as reflected in the X12N 276/277 version 004010X093A1 Implementation Guide, will be translated. Submitting invalid data, based on the Implementation Guide, will lead to file rejection.

• All dates that are submitted on an incoming 276 Claim Status Request Transaction should 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 Status Request or the applicable interchange (transmission).

• 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 status submission.

• Transaction Set Purpose Code (BHT02) must equal ‘13’ (REQUEST).

• First Coast Service Options, Inc. will reject an interchange (transmission) that is submitted with an invalid value in GS03 (Application Receivers Code) based on the carrier definition.

• 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.

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

• Only valid qualifiers for Medicare should be submitted on incoming 276 Claim Status Request Transactions. Any qualifiers submitted for Medicare processing not defined for use in Medicare billing will cause the individual request or the transaction to be rejected.

• First Coast Service Options, Inc. will not accept a 997 response transaction from trading partners in response to their retrieval of the electronic 277 Claims Status Response.

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

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

• First Coast Service Options, Inc. will return the version of the 276 inbound transaction in GS08 (Version/Release/Industry Identifier Code) of the 997.

• Data Elements that are defined by a previous qualifier will contain valid and appropriate information for the noted qualifier.

Examples:

• If ISA07 has a value of “27” indicating a carrier ID Number, then ISA08 will contain a valid carrier ID Number.

• NM108 has a value of “XX” indicating an NPI, then NM109 will contain a valid NPI for the identified provider.

• First Coast Service Options, Inc keeps its online paid claims file for at least 15 months. After that time, paid claims are stored in an off-line paid claims history file. A 276 inquiry for a claim that has reached history will result in a 277 response with a health care claim status code of “35” (claim not found).

Delimiters

The Functional Acknowledgment report (997) will be returned to you using the delimiters specified within the 276. If you would like the 997 to be returned with other delimiters, you will need to notify us of those override delimiters. Note: if you use the tilde (~) as a segment delimiter your 997 will be returned to you as one string, 'unwrapped'.

276 Request Transaction

Page	Data Segment Name	Segment or Data Element	Supported Values	Requirement
B.4	Interchange Control Header	ISA05	ZZ	Interchange Identity Qualifier for ISA06 Submitter uses “ZZ” value.
B.4	Interchange Control Header	ISA06		Interchange Sender ID. Submitter chooses and enters a value later used by the contractor for sending back the 277.
B.4	Interchange Control Header	ISA07	27,28	Carrier submitter uses a “27” as the Interchange ID. Qualifier for ISA08.
B.5	Interchange Control Header	ISA08		Interchange Receiver ID. Submitter uses the CMS assigned Medicare carrier number. Enter 00590.
28 addenda	Functional Header Group	GS01		Submitter uses “HR” to designate the 276.
28 addenda	Functional Header Group	GS02		Submitter uses code agreed to by Trading Partners.
28 addenda	Functional Header Group	GS03		Submitter uses code agreed to by Trading Partners.
29 addenda	Functional Header Group	GS05		Submitter uses the recommended HHMM format.
55	Payer Name	NM108	PI	Submitter uses the code “PI” to identify that the carrier identifier will follow.
56	Payer Name	NM109		Submitter uses the identifier provided by the carrier .
57	Payer Contact Information			This segment is not needed for Medicare.
63	Information Receiver Name	NM108	46	This is the individual or organization requesting to receive the status information.
63	Information Receiver Name	NM109		Submitter uses identification code as assigned by the carrier.
68	Provider Name	NM108	XX	Submitter uses the “XX” qualifier for the National Provider Identifier (NPI) in NM109.
69	Provider Name	NM109		Submitter enters the NPI number.
75	Subscriber Name	NM108	MI	Submitter uses the “MI” qualifier for the patient’s Medicare health insurance claim (HIC) number entered in NM109.
76	Subscriber Name	NM109		Submitter enters the patient’s Medicare health insurance claim (HIC) number.
14 addenda	Group Number	REF		This segment is not used for inquiries to Medicare.

277 Response Transaction

Page	Data Segment Name	Segment or Data Element	Supported Values	Requirement
B.4	Interchange Control Header	ISA05	27, 28	Contractor enters the valid code as a qualifier for ISA06 for Carrier Identification Number as assigned by CMS. Carriers enter “27”.
B.4	Interchange Control Header	ISA06		Contractor enters the Carrier Identification Number as assigned by CMS.
B.4	Interchange Control Header	ISA07	ZZ	Contractor enters “ZZ” Qualifier for ISA08.
B.5	Interchange Control Header	ISA08		Contractor enters the ID number assigned by the 276 submitter in the 276, ISA06.
28 addenda	Functional Header Group	GS01		Contractor uses code “HN” to designate the 277.
28 addenda	Functional Header Group	GS02		Contractor uses code agreed to by Trading Partners.
28 addenda	Functional Header Group	GS03		Contractor uses code agreed to by Trading Partners.
29 addenda	Functional Header Group	GS05		Contractor enters the recommended HHMM format.
131	Payer Name	NM108	PI	Contractor enters the “PI” qualifier for NM109.
132	Payer Name	NM109		Contractor enters identification code.

Reports

If your file contains incorrect enveloping information (ISA, GS, ST, SE, GE, and IEA segments), a TA1 or a negative 997 will be returned to you. If you need assistance reading your TA1, please contact Mike Morton at 904-791-8610. 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 X12N Standard. Standard requirements can be found in the 4010A1 Implementation Guide (IG) under the “STANDARD” heading for each segment.

When your file passes the Standard, they are then reviewed for X12 Implementation Guide (IG) requirements. X12 Implementation Guide requirements can be found in the 4010A1 Implementation Guide under the ‘IMPLEMENTATION’ heading for each segment and in the body of the segment information. Note: If you received a 997 indicating your file rejected, you will not receive any further word from us regarding that file. You must make the corrections indicated on the 997 and resubmit the file.

Schedule Your Optional Testing Appointment

Providers, agents, and clearinghouses are not required, in most cases, to be tested on their 276/277 transaction prior to initial submission of a 276 or request for receipt of a 277. You are required to notify Medicare when you plan to begin submitting 276 version 4010A1 queries. Those who prefer advance testing, to assure system compatibility of version 4010A1 of the 276/277, must schedule testing. Appointment slots will be assigned on a first-come, first-served basis. To schedule an appointment, call Medicare EDI @ 904-791-5977 option 4.