SCAN HEALTH PLAN. 837-I Companion Guide

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_________________________________________________________

SCAN HEALTH PLAN

Standard Companion Guide Transaction Information

Instructions related to the 837 Health Care Claim: Institutional

Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2

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Preface

This Companion Guide contains information to assist SCAN’s Trading Partners in the submission of encounter data. The SCAN Companion Guide is under development and the information in this version reflects current decisions and will be modified on a regular basis. All versions of the SCAN Companion Guide are identified by a version number which is located in the version control log on the last page of the document. Users should verify they are using the most current. Questions regarding the contents of the SCAN Companion Guide should be directed to

[email protected]

1 Introduction ...3

1.1 Scope... 3

1.2 Overview... 3

1.3 Definition of key Terms... 3

1.4 References... 3

2 Contact Information ...4

3 Control Segments/envelopes...4

3.1 ISA-IEA ... 4 3.2 GS-GE ... 5 3.3 ST-SE ... 6 3.4 BHT... 7

4 837 Institutional: Data Element Table...7

5 Appendices...15

5.1 Business Rules ... 15

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1 Introduction

1.1 Scope

The SCAN Companion Guide for the 837-I transactions addresses how Trading Partners should send encounter data to SCAN. This Companion Guide must be used in conjunction with the associated 837-I Implementation Guide (TR3). The instructions in this Companion Guide are not intended to be a stand-alone requirements document.

1.2 Overview

This Companion Guide includes information needed for Trading Partners to create Institutional encounter data files for transmission to SCAN Health Plan. The information is organized in the sections listed below:

 Contacts and Resources: This section includes telephone numbers and email addresses for SCAN as well as applicable website resources.

 Required Encounter Data: This section includes fields required by SCAN for Encounter Data processing in grids with required Loop/Segment/data elements/value/note/constraint.

 Version control Log: This section contains the revision history of the document.

1.3 Definition of key Terms

Term

Definition

SCAN SCAN Health Plan (MAO)

CMS Centers for Medicare and Medicaid Services

1.4 References

Trading Partners can access our regularly updated FAQ list, our webinars and other documentation online under the Provider Tools section of the SCAN website.

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2 Contact Information

2.1 SCAN Contracts

Name

Title

Contact Phone

Contact Email

Char Beecher Manager, EDI 562-308-1126 [email protected]

Marc Carren Director, Informatics and Data Interchange 562-997-1821 [email protected] Viraj Desilva Sr. Encounter Data Specialist - Technical 562-989-4450 [email protected]

Irina Masharova EDI Developer 562-308-4335 [email protected]

2.2 Resources

Resource

Website

ANSI ASC X12 TR3 Implementation Guides

http://www.wpc-edi.com/

Washington Publishing Company Health Care Code Sets

http://www.wpc-edi.com/

SCAN Provider Tools Website

http://www.scanhealthplan.com/article/physicianshospitals/

fullencounterdata/fullencounterdata.html

3 Control Segments/envelopes

3.1 ISA-IEA

There are several elements within the ISA-IEA interchange that must be populated specifically for SCAN. Table 2 below provides SCAN Required (ISA-IEA) data elements.

Table 2 – ISA-IEA INTERCHANGE ELEMENTS

Loop Segment Data Element Comments/Value Segment or Loop_Requirement Note

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Header ISA ISA02: Authorization_Information Required Use 10 blank spaces

Header ISA ISA03: Security Information_Qualifier “00” Required _Present"00" = No Security Information

Header ISA ISA04:Security Information Required Use 10 blank spaces

Header ISA ISA05: Interchange ID_Qualifier “ZZ” Required "ZZ" = Mutually Defined Header ISA ISA06: Interchange Sender ID Use the Submitter IDassigned by SCAN

Health Plan Required

Please contact SCAN to obtain your Submitter Id.

Header ISA ISA07:Interchange ID Qualifier “ZZ” Required "ZZ" = Mutually Defined Header ISA ISA08: Interchange Receiver_ID "SCANCA3800" Required

Header ISA ISA09: Interchange Date Transmission Date_(YYMMDD) Required

Header ISA ISA13: Interchange Control_Number Control Number from_System Required Must be a fixed length with nine (9)_{characters and match IEA02} Header ISA ISA14: Acknowledgement_Requested “0”_“1” Required

"0" = No Acknowledgement Requested

“1” = Interchange Acknowledgment Requested (TA1 or 999)

Header ISA ISA15: Usage Indicator "P"_“T” Required

"T" = Test (Please coordinate with SCAN if you are sending Test data) "P" = Production (value must be "P" for production data)

Trailer IEA IEA02: Interchange Control_Number Required Must match the value in ISA13.

3.2 GS-GE

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TABLE 3 - GS-GE FUNCTIONAL GROUP ELEMENTS

Loop Segment Data Element Comments Segment or Loop Requirement Note

Header GS GS01: Functional

Identifier Code "HC" Required

Header GS GS02:

Application Sender's Code

Use the Submitter ID assigned by SCAN Health Plan

Required Please contact SCAN to obtain your

Submitter Id.

Header GS GS03:

Application Receiver's Code

"SCANCA3800" Required This value must match the value in

ISA08

Header GS GS06: Group

Control Number Required This value must match the value inGE02

Header GS GS08:

Version/Release Industry ID Code

“005010X223A2” Required

Trailer GE GE02: Group

Control Number Required This Value must match the value inGS06

3.3 ST-SE

There are several elements that must be populated specifically for encounter data purposes. Table 4 provides transaction set (ST-SE) specific elements.

TABLE 4 - ST-SE TRANSACTION SET HEADER AND TRAILER ELEMENTS

Header ST ST01: Transaction Set

ID Code "837" Required

Header ST ST02: Transaction Set

Control Number Required This value must match the value inSE02

Header ST ST03: Implementation

Convention Reference “005010X223A2” Required Trailer SE SE01: Number of

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Trailer SE SE02: Transaction Set

Control Number Required This value must match the value inST02

3.4 BHT

There are several elements that must be populated specifically for encounter data purposes. Table 5 provides BHT specific elements.

Table 5 – BHT - BEGINNING OF HIERARCHICAL TRANSACTION

Header BHT BHT01: Hierarchical

Structure Code "0019" Required

Header BHT BHT03: Reference

Identification Required Batch Control Number

Header BHT BHT06: Transaction

Type Code “RP”“CH” Required "RP" = Encounters“CH” = Chargeable

4 837 Institutional: Data Element Table

Within the ST-SE transaction set, there are multiple loops, segments, and data elements that provide billing provider, subscriber, and patient level information.

The 837 Institutional Data Element table provides users with Loops, Segments, Data Elements, values and notes as specific to SCAN. Not all data elements listed in the table are required; however, if they are used, the table reflects the values SCAN expects to see. Trading Partners should refer to 837I 5010 TR3 implementation guide for the complete transaction set and requirements.

TABLE 6 - 837 INSTITUTIONAL HEALTH CARE CLAIM

Loop Segment Data Element Comments/Value Segment or Loop Requirement Note

1000A:

Submitter Name NM1 NM102: EntityType Qualifier “2” Required "2" (Non Person) 1000A:

Submitter Name NM1 NM109:SubmitterIdentifier Submitter IDUse the assigned by SCAN Health Plan

Required Please contact SCAN to obtain

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1000A:

Submitter Name PER PER03:Communication Number Qualifier

"TE" Required 1000A:

Submitter Name PER PER04:COMMUNICATION NUMBER

Required 1000A:

"EM" Situational 1000A:

Submitter Name PER PER06:Communication Number

Situational Email address of contact person 1000A:

"FX" Situational 1000A:

Situational Fax number

1000B:

Receiver Name NM1 NM102: EntityType Qualifier "2" Required "2" = Non Person 1000B:

Receiver Name NM1 NM103: ReceiverName "SCAN HealthPlan" Required 1000B:

Receiver Name NM1 NM109: ReceiverID "SCANCA3800" Required 2010AA: Billing Provider Name NM1 NM108: Billing Provider ID Qualifier

"XX" Required NPI Identifier

2010AA: Billing Provider Name

NM1 NM109: Billing

Provider Identifier Billing ProviderNPI Required If Billing Provider is Exempt, useCMS default NPI ‘1999999976’ 2010AA:

Billing Provider City/State/Zip

N4 N403: Zip Code “999999998” Required The full nine (9) digits of the ZIP

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2010AA: BILLING

PROVIDER TAX INDENTIFICATION

REF REF01: Billing

Provider TAX ID “EI” Required EI=Tax Identification Number

2000B: Subscriber

Information SBR SBR01: Payerresponsibility Number code

"S" Required Code identifying the insurance

carrier's level of responsibility for a payment of a claim

"P" = Primary "S" = Secondary "T" = Tertiary 2000B: Subscriber

Information SBR SBR09: ClaimFiling Indicator Code

"16" Required Must be populated with a value of

16 – Health Maintenance Organization Medicare Risk. Must be identical to the value populated in Loop 2320, SBR09 2010BA:

Subscriber Name NM1 NM108: SubscriberId Qualifier "MI" Required Member ID 2010BA:

Subscriber Name NM1 NM109: SubscriberPrimary Identifier SCAN Member ID Required SCAN Member ID is 11 digitslong and begins with 310 or 311 2010BB: Payer

Name NM1 NM103: PayerName "SCAN HealthPlan" Required 2010BB: Payer

Name NM1 NM108: Payer IDQualifier "XV"“PI” Required 2010BB: Payer

Name NM1 NM109: PayerIdentification "SCANCA3800" Required 2010BB: Payer

Address N3 N301: PayerAddress Line "3800 KilroyAirport Way" Required SCAN Address line 2010BB: Payer

City/State/Zip N4 N401: Payer CityName "Long Beach" Required 2010BB: Payer

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2010BB: Payer

City/State/Zip N4 N403: Payer ZIPCode "90806" Required

2300:

Claim Information CLM CLM02: TotalClaim Charge Amount

Required Must balance to the sum SV2

service lines in Loop 2400 2300:

Claim Information CLM CLM05-3: ClaimFrequency Type Code “1”=Original claim submission “2”=Interim – First Claim “3”=Interim – Continuing Claim “4”=Interim – Last Claim “7”=Replacement “8”=Deletion “9” Final Claim for a Home Health PPS Episode

Required

2300:

Claim Information DTP DTP03: DischargeTime Situational Hours (HH) are expressed as “00”for midnight, “01” for 1A.M., and so on through “23” for 11P.M. Minutes (MM) are expressed as “00” through “59”. If the actual minutes are not known, use a default of “00”

2300:

Claim Information CLM CLM08: BenefitsAssignment Certification Indicator

"Y" = Yes

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2300: Claim

Information PWK PWK01: ReportType Code "09" Situational 09: Populated for chart reviewsubmission only – Indicates chart review additions and deletions 2300: Claim

Information PWK PWK02:Attachment

Transmission Code

"AA" Situational Populated for chart review

2300: Claim

Information CN1 CN101: ContractType Code “05” Situational Populated for capitatedarrangements. Applies to the entire claim.

2300: Claim

Information REF REF01: OriginalReference Number Qualifier

“F8" Situational Populated for Linked Chart

Review, while CLM05-3 remains “1” for original encounter. Chart review data can also be sent as a correct/replace review in which CLM05-3 would be “7.”

2300:

Claim Information REF REF02: PayerClaim Control Number

Situational Identifies ICN from original claim when submitting adjustment or chart review data.

2300:

Claim Information REF REF01: MedicalRecord Identification Qualifier

“EA” Situational Populated for Chart Review Data.

REF02, will either be “8” or will contain the diagnosis codes to delete from the original encounter.

2300: Claim Information -Medical Record Number

REF REF02: Medical Record

Identification

“8” Situational Chart review delete diagnosis

code submissions only Identifies the diagnosis code populated in Loop

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Deleted Diagnosis Code(s)

Diagnosis code(s) that must be deleted from the encounter ICN in Loop 2300, REF02for “chart review – add and delete specific diagnosis codes on a single encounter” submissions only.

2300: Claim Note NTE NTE01 “ADD” Situational Used only for submitting Proxy

Data for a limited set of circumstances.

2300: Claim Note NTE NTE02: Proxy Data Reason Code 036040

044 048 052 056

Situational 036: Rejected Line Extraction 040: Medicaid Service Line Extraction

044: EDS Acceptable Anesthesia Modifier

048: Default NPI for atypical provider

052: Default EIN for atypical providers

056: Chart Review Default Procedure Codes

2300: Claim

Information HI HI01-2 Value Code A0 Required on all ambulanceencounters

2300: Claim

Information HI HI01-5 Value CodeAmount Must include the ambulancepick-up location ZIP Code+4, when available, in the following format: xxxxxxxx.x 2320: Other Subscriber Information SBR SBR01: Payer Responsibility Sequence Number Code

"P" Required Code identifying the insurance

carrier's level of responsibility for a payment of a claim.

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(COB), Loop 2320 must be Primary. "P" = Primary "S" = Secondary "T" = Tertiary 2320: Other Subscriber Information SBR SBR09: Claim

Filing Indicator "16" Required Must be identical to the value inLoop 2000B, SBR09

2320: Claims Level

Adjustment CAS CAS02:Adjustment Reason Code

Situational Required when service line is denied in the MAO or other entities’ adjudication system 2320: COB Payer

Paid Amount AMT AMT02: PayerPaid Amount amount Required claims as encounters.CMS requires Post Adjudicated Populate with the actual amount adjusted or 0.00 if there is no adjustment

2320: Coverage

Information OI OI03: BenefitsAssignment Certification Indicator

"Y" = Yes

"N" = No Required Must match the value in Loop2300, CLM08

2330A: Other

Subscriber Name NM1 NM108:Identification Code Qualifier

"MI" Required

2330A: Other

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2330B: Other

Payer Name NM1 NM108:Identification Code Qualifier

"XV"

“PI” Required

2330B: Other

Payer Name NM1 NM109: OtherPayer Primary Identifier Required 2330B: Other Payer Claim Adjustment Indicator

REF REF01: Reference Identification Qualifier

"T4" Required Must be populated because the

claim is being sent in the payer-to-payer COB model, and the destination payer is secondary to the payer identified in this loop. The payer may be in both instances the same, SCAN 2330B: Other

Payer Claim Adjustment Indicator

REF REF02: Other

Payer Claim Adjustment Indicator

"Y" Required Must be populated because the

claim is being sent in the payer-to-payer COB model, and the destination payer is secondary to the payer identified in this loop. 2430: Line

Adjudication System

SVD SVD02: Service

Line Paid Amount Amount Required The SVD segment is required byCMS for post adjudicated encounters.

Zero (0) is acceptable for this element 2430: Line Adjudication System CAS CAS02: Adjustment Reason Code

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5 Appendices

5.1 Business Rules

5.1.1 Encounter File size must be limited to 5000 CLM segments per file.

5.1.2 Trading Partners must submit encounters to SCAN no less than twice per week.

5.1.3 SCAN allows “duplicate” encounter data to be submitted when only the diagnosis codes are different. Often times, a provider partner\medical group has a need to send more diagnosis codes than the v5010 837I data set allows.

5.1.4 File Naming Convention: <Clearinghouse Batchid>_<Clearinghouse Name>_ENCOUNTERS_<formatype (837I or 837P)>_<Date in YYYYMMDD>_iterator (where applicable)

Example: 12345_ABCFileProcessors_ ENCOUNTERS _837I_20130417 12345_ABCFileProcessors _ ENCOUNTERS _837I_20130417_1 (iterators of 1,2,3,etc. used when batches are split, or batch resent, etc.)

SCAN HEALTH PLAN. 837-I Companion Guide

_________________________________________________________

SCAN HEALTH PLAN

Standard Companion Guide Transaction Information

Instructions related to the 837 Health Care Claim: Institutional

Transaction based on ASC X12 Technical Report Type 3 (TR3), Version 005010X223A2

Preface

Table of Contents

1

Introduction ...3

2

Contact Information ...4

3

Control Segments/envelopes...4

4

837 Institutional: Data Element Table...7

5

Appendices...15

1 Introduction

1.1 Scope

1.2 Overview

1.3 Definition of key Terms

Term

Definition

1.4 References

2 Contact Information

2.1 SCAN Contracts

Name

Title

Contact Phone

Contact Email

2.2 Resources

Resource

Website

ANSI ASC X12 TR3 Implementation Guides

http://www.wpc-edi.com/

Washington Publishing Company Health Care Code Sets

http://www.wpc-edi.com/

SCAN Provider Tools Website

http://www.scanhealthplan.com/article/physicianshospitals/

fullencounterdata/fullencounterdata.html

3 Control Segments/envelopes

3.1 ISA-IEA

3.2 GS-GE

3.3 ST-SE

3.4 BHT

4 837 Institutional: Data Element Table

5 Appendices

5.1 Business Rules

5.2 Version Control Log

Version

Version or Change Explanation

By

Date