Part B NJ News: Empire Medicare Services (EMS) New York Region Trading Partner Agreement for Claim Submission ASC X12N 837 Version 4010A1 Professional Healthcare Claim (Medicare Part B)

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Empire Medicare Services (EMS) New York Region Trading Partner Agreement for Claim Submission ASC X12N 837 Version 4010A1 Professional Healthcare Claim (Medicare Part B)

Important Updates to the 837 Companion Document

Empire Business Requirements:

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 ANSI X12N 837 implementation guides have been established as the standards of compliance for claim transactions. The implementation guides for each transaction are available electronically at www.wpc-edi.com.

The following information is intended to serve only as a companion document to the HIPAA ANSI X12N 837 implementation guides. 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 VMS System of Empire Medicare Services Contractor number 00803 . The information in this document is subject to change. Changes will be communicated in the standard Empire Medicare Services Newsbrief and on Empire Medicare Services Web site: www.empiremedicare.com. This companion document supplements, but does not contradict any requirements in the X12N 837 Professional implementation guide. Additional companion documents/trading partner agreements will be developed for use with other HIPAA standards, as they become available.

The Health Insurance Portability and Accountability Act (HIPAA) commissioned the use of the American National Standards Institute (ANSI) 837 version 4010A1 claim transaction set, as the standard mode for Electronic Data Interchange (EDI). The above information is intended to serve as a companion document to the HIPAA ANSI X12N 837 Version 4010A1 Implementation Guide. The use of these documents is solely for the purpose of clarification. This information describes specific requirements to be used for processing the 4010A1 in the Empire Medicare Services Part B New York. Additional companion documents/trading partner agreements will be developed for use with other HIPAA standards, as they become available.

Changes may be made on an as need basis, especially in the beginning of the HIPAA Implementation. Updates can be found on our website: http://www.empiremedicare.com.

If you have any further questions you can contact EMC Marketing at (212) 476-7934 or (212) 476 7952.

I. SUMMARY OF CHANGES: The current companion document language is being revised to address corrections, as well as provide additional language to cover items not addressed in the current companion document. The summary of changes to the document are shown below:

Removal of the REQUIRED statement “Currency code (CUR02) must equal USA”. The CUR segment is situational and is only to be used when financial amounts submitted on the claim are for services provided in a currency that is not normally used by the receiver. The situation does not apply to Medicare;
Revision to the statement “The only valid values for CLM05-3 (Claim Frequency Type Code) are '1' (ORIGINAL) and '7' (REPLACEMENT). Claims with a value of '7' will be processed as original claims and may result in duplicate claim rejection. The claims processing system does not process electronic replacements” to allow only 1 (ORIGINAL);
Revision to the statement “Purchased diagnostic tests (PDT) amounts should be submitted at the detail line level (Loop 2400), not at the header claim level (Loop 2300). PDT amounts submitted at the header claim level (Loop 2300) will be ignored” which provides clarification that the PS1 segment is required at the 2400 loop for all purchased services;
Revision to the statement “Claims that contain percentage amounts submitted with more than two positions to the left or the right of the decimal will be rejected.” The language is being revised to be clear that percent values with less than two positions can be accepted;
Addition of a new statement indicating that taxonomy codes are not required for Medicare;
Addition of a new statement indicating that “D” (Pilot) in the REF02 is not a valid value for Medicare;
Addition of three new statements related to the ISA;
Addition of two new statements that provide clarification of the maximum value for the three service unit’s qualifiers (UN units, MJ anesthesia minutes, and F2 international units);
Addition of a new statement indicating that Medicare will only process anesthesia claims submitted with minutes.

Description - General Statements			Language		Page
				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. In certain circumstances, the percent can be less than two positions to the left or the right. Percent amounts that exceed their COBOL PIC clause will be rejected
				Empire Medicare Services 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
				The incoming 837 transactions utilize delimiters from the following list: >, *, ~, ^, \|, and :. Submitting delimiters not supported within this list may cause an interchange (transmission) 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
				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 www.wpc-edi.com/codes. Claims submitted with invalid taxonomy codes will be rejected
				All dates that are submitted on an incoming 837 claim 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 or the applicable interchange (transmission)
				Empire Medicare Services may reject an interchange (transmission) submitted with more than 9,999 loops
				Empire Medicare Services will reject an interchange (transmission) with more than 5,000 CLM segments (claims) submitted per transaction
				Compression of files is not supported for transmissions between the submitter and Empire Medicare Services
				Only valid qualifiers for Medicare should be submitted on incoming 837 claim transactions. Any qualifiers submitted for Medicare processing 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 Empire Medicare Services processing system will only use the first two modifiers for adjudication and payment determination of claims.
Interchange Control Header
	ISA05	Interchange ID Qualifier		Empire Medicare Services will reject an interchange (transmission) that does not contain ZZ in ISA05	B.4
	ISA06	Interchange Sender ID		Empire Medicare Services will reject an interchange (transmission) that does not contain a valid ID in ISA06	B.4
	ISA07	Interchange ID Qualifier		Empire Medicare Services will reject an interchange (transmission) that does not contain 27 in ISA07	B.4
	ISA08	Interchange Receiver ID		Empire Medicare Services will reject an interchange (transmission) that does not contain 00803. Each individual Contractor determines this code	B.5
Loop	Transaction Set
				Empire Medicare Services 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
1000A	NM109	Submitter ID		Empire Medicare Services will reject an interchange (transmission) that is submitted with a submitter identification number that is not authorized for electronic claim submission	69
1000B	NM109	Receiver Primary Identifier		Empire Medicare Services will reject an interchange (transmission) that is not submitted with a valid carrier code.(NM1) Each individual Contractor determines this code	75
2000B	SBR02, SBR09	Subscriber Information		For Medicare, the subscriber is always the same as the patient (SBR02=18, SBR09=MB). The Patient Hierarchical Level (2000C loop) is not used	111
2010BD		Credit/Debit Card Information		Do not use Credit/Debit card information to bill Medicare (2300 loop, AMT01=MA and 2010BD loop)	150
Loop	Claim Information
2300	CLM02	Total Submitted Charges		Negative values submitted in CLM02 will not be processed and will result in the claim being rejected	172
2300	CLM02	Total Submitted Charges		Total submitted charges (CLM02) must equal the sum of the line item charge amounts (SV102)	172
2300	CLM05-3	Claim Frequency Type Code		The only valid value for CLM05-3 is '1' (ORIGINAL). Claims with a value other than "1" may be rejected	173
2300	CLM20	Delay Reason Code		Data submitted in CLM20 will not be used for processing	179
2300	PWK	Claim Supplemental Information		Any data submitted in the PWK (Paperwork) segment may not be considered for processing	214
2300	AMT01	Credit/Debit Card Maximum Amount		Do not use Credit/Debit card information to bill Medicare (2300 loop, AMT01=MA and 2010BD loop)	219
2300	AMT02	Patient Amount Paid		Negative values submitted in the following fields may not be processed and may result in the claim being rejected: AMT02	220
2300	AMT02	Total Purchased Service Amount		Negative values submitted in the following fields may not be processed and may result in the claim being rejected: AMT02	221
2300	CR102, CR106	Ambulance Transport Information		Negative values submitted in the following fields may not be processed and may result in the claim being rejected: CR102, CR106	249,250
2300	HI	Health Care Diagnosis Code		Diagnosis codes have a maximum size of five (5). Medicare does not accept decimal points in diagnosis codes	265
2300	HI	Health Care Diagnosis Code		You may send up to eight diagnosis codes per claim; however, the last four diagnosis codes will not be considered in processing	265
2320	AMT02	Coordination of Benefits Amounts		Negative values submitted in the following fields may not be processed and may result in the claim being rejected: AMT02	332 333
2400	SV104	Professional Service		The max value for units (qualifier MJ) cannot exceed 4 bytes numeric. Claims for anesthesia services that exceed this value will be rejected.(SV104)	400
2400	SV104	Professional Service		Anesthesia claims must be submitted with minutes (qualifier MJ). Claims for anesthesia services that do not contain minutes may be rejected. (SV104)	403
2400	SV104	Professional Service		SV104 (Service unit counts) (units or minutes) cannot exceed 999.9	403
2400	SV104	Professional Service		Negative values submitted may not be processed and may result in the claim being rejected. (SV104)	403
2400	PS1	Purchased Service		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	489
2400	PS102	Purchased Service		Negative values submitted in PS102 may not be processed and may result in the claim being rejected	490
997 - Functional Acknowledgement
				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	B.15
				Empire Medicare Services will return the version of the 837 inbound transaction in GS08 (Version/Release/Industry Identifier Code) of the 997

Posted: 01/16/2004