Companion Document

837P 837 Professional Health Care Claim Basic Instructions This section provides information to help you prepare for the ANSI ASC X12N 837 Health Care transaction for professional claims. The remaining sections of this appendix include tables that provide information about 837 Claim segments and data elements that require specific instructions to efficiently process through Anthem Blue Cross and Blue Shield, Connecticut, Maine, and New Hampshire (East Region) systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide “Health Care Claim: Professional, 837, ASC X12N 837 (004010X098),” May 2000, and the subsequent Addenda (004010X098A1), October 2002, published by the Washington Publishing Co. EDI Transmission Structure Communications Transport Protocol Interchange Control Header (ISA)

Functional Group Header (GS)

Transaction Set Transaction Set

Functional Group 1 Wrap

Transaction Set Header (ST)

Transaction Set Header (ST)

Detail Segment 1 Transaction Set Trailer (SE)

EDI Transaction Structure Interchange Control Header (ISA)

Detail Segment 2

Functional Group Header (GS)

Transaction Set Trailer (SE)

Transaction Set Header (ST)

Header

Envelope

Transaction Set Header (ST)

Envelope

Transaction Set

Transaction Set Header (ST)

Transaction Set

Functional Group Header (GS)

Envelope

Functional Group Trailer (GE)

Functional Group 2 Wrap

Interchange Control Wrap

Communications Session

Functional Group Header (GS)

Detail Summary

Detail Segment 1

Transaction Set Trailer (SE)

Transaction Set Trailer (SE) Functional Group Trailer (GE) I t

h

C

t

lT

il

(IEA)

Detail Segment 2

Transaction Set Trailer (SE) Functional Group Trailer (GE)

Interchange Control Trailer (IEA)

Communications Transport Protocol

Anthem Blue Cross and Blue Shield - East Region

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X12 and HIPAA Compliance Checking, and Business Edits Level 1. The East Region returns a 997 Functional Acknowledgment to the submitter for every inbound 837 transaction received. Each transaction passes through edits to ensure that it is X12 compliant. If the X12 syntax or any other aspect of the 837 is not X12 compliant, the 997 Functional Acknowledgment will also report the Level 1 errors in AK segments and indicate that the entire transaction set has been rejected. Level 2. HIPAA Implementation Guide edits are strictly enforced. In addition, the East Region applies business edits, such as provider and member number validation to each 837 transaction. If a HIPAA compliance, code set or business error is encountered, a Level 2 Status Report will be returned to the submitter indicating the particular claim has failed.

2

HIPAA Compliant Codes Follow the 837 Professional IG precisely. Use HIPAA-Compliant codes from current versions of the sources listed in the 837 Professional IG, Appendix C: External Code Sources.

3

Uppercase Letters All alpha characters must be submitted in UPPERCASE letters only.

4

Diagnosis Codes According to the 837 Professional IG (P.254), a transaction is not X12 compliant if decimal points are used in diagnosis codes – Loop 2300 HI Health Care Diagnosis Code. Therefore, should a diagnosis code contain a decimal point, the East Region will return a 997 Functional Acknowledgment to the submitter indicating that the transaction has been rejected.

5

Delimiters The East Region accepts any of the standard delimiters as defined by the ANSI standards. The more commonly used delimiters include the following:

Data Element Separator, Asterisk, (*) Sub-Element Separator, Colon, (:) Segment Terminator, Tilde (~) These delimiters are for illustration purposes only and are not specific recommendations or requirements.

Anthem Blue Cross and Blue Shield - East Region

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Numeric Values, Monetary Amounts and Unit Amounts

East Region adjudication systems support numeric values that are consistent with

the current NSF Version 3.01. Values which require a field length greater than those specified by NSF Version 3.01 will not pass our business rule edits.

The East Region pays all claims in US dollars and, therefore, accepts monetary amounts

in US dollars only. If codes related to foreign currencies are used, then a Level 2 Status Report will be returned to the submitter and the claim will be rejected.

The East Region recognizes unit amounts in whole numbers only. The East Region recognizes unit amounts in values of less than 9999 and greater than or equal to zero.

If

negative values are submitted in any of the two data elements in Loop 2400 SV1 Professional Service (See 837P IG, P.383), then the East Region will return a Level 2 Status Report to the submitter and reject the claim.

SV102 Monetary Amount – Line Item Charge Amount SV104 Quantity – Service Unit Count

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Coordination of Benefits Specific 837 data elements work together to coordinate benefits between the East Region and Medicare or other carriers. The tables in the section that follow (Loop 2320), identify the data elements that pertain to Coordination of Benefits (COB) with Medicare (Providerto-Payer-to-Payer COB model) and with other carriers (Payer-to-Provider-to-Payer COB model). The East Region recognizes submission of an 837 transaction to a sequential payer populated with data from the previous payer’s 835 (Health Care Claim Payment/Advice). Based on the information provided and the level of policy, the claim will be adjudicated without the paper copy of the Explanation of Benefits from Medicare or the primary carrier. When more than one payer is involved on a claim, payer sequencing is as follows:

If a secondary payer is indicated, then all the data elements from the primary payer must also be present.

If a tertiary payer is involved, then all the data elements from the primary and secondary payers must also be present. If these data elements are omitted, the East Region will fail the particular claim.

Anthem Blue Cross and Blue Shield - East Region

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Sending Attachments to Support a Claim To expedite processing of a claim:

If you are sending an attachment to support a claim, populate Loop 2300 PWK02 with a value of ‘BM’ (By Mail).

Download the Attachment Face Sheet from www.anthem.com/edi Mail the attachment to the appropriate address listed at the bottom of the Attachment Face Sheet on the same day the claim is submitted.

Do not send a copy of the claim with the attachment. Send the completed Attachment Face Sheet with the attachment. The Attachment Face Sheet includes the following fields:

Anthem East (CT, ME, NH) Attachment Face Sheet Claim Supplemental Information PWK; Loop 2300 Original Service Line Number PWK; Loop 2400 Line Supplemental Information

1)

Date Claim Transmitted

2)

Line of Business (Professional, Institutional)

3)

Member’s Contract Number (Including Prefix)

Member’s Contract Number (Prefix Included)

4)

Patient Name

Name of Patient

5)

Date of Service

6)

Provider Name

State Services were Rendered In

7)

State Where Services Were Rendered

Identification Code (Attachment Control #)

8)

Identification Code. This is the Attachment Control Number, an alphanumeric code created by the provider for his records.

The paper documentation included in this mailing supports the electronically submitted claim. Date Claim Transmitted Line of Business

ð Professional

ð Institutional

Date of Service Name of Provider

(If the correspondence is not received in 7 calendar days and is necessary to adjudicate the claim, Anthem will fail the claim. After 7 calendar days, the claim will be reviewed on an inquiry basis only.) Anthem BCBS Professional PO Box 533 North Haven, CT 06473

Anthem BCBS Institutional PO Box 537 North Haven, CT 06473

BlueCare Family Plan (CT only) Professional PO Box 1076 North Haven, CT 06473

P00292

FEP Claims CT PO Box 37790 Louisville, KY 40233-7790

BlueCare Family Plan (CT only) Institutional PO Box 1077 North Haven, CT 06473

FEP Claims ME PO BX 37980 Louisville, KY 40233-7980

National Claims PO Box 726 North Haven, CT 06473

FEP Claims NH PO Box 36500 Louisville, KY 40233-6500

Teamster’s Claims PO Box 726 North Haven, CT 06473

An independent licensee of the Blue Cross and Blue Shield Association. â Registered marks of the Blue Cross and Blue Shield Association.

Anthem Blue Cross and Blue Shield - East Region

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Claim Supplement Information

Claim File received with PWK segment populated

Professional Health Care Claim Attachment to Support a Claim

Attachment Face Sheet

By Mail

June 15

June 16

June 17

June 18

June 19

June 20

June 21

June 22

All documentation must be received within 7 calendar days of the electronic submission. If supporting documentation is not received but is required to process the claim, the East Region will deny the claim. For example (as shown above):

On June 15, a claim is received with the PWK segment populated. On June 22, the 7 day time period expires. The claim will be denied if the attachment has not been received and is required for adjudication.

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Taxonomy Codes (PRV) The Healthcare Provider Taxonomy code set divides health care providers into hierarchical groupings by type, classification, and specialization, and assigns a code to each grouping. The Taxonomy consists of two parts: individuals (e.g., physicians) and non-individuals (e.g., ambulatory health care facilities). All codes are alphanumeric and are 10 positions in length. These codes are not “assigned” to health care providers; rather, health care providers select the taxonomy code(s) that most closely represents their education, license, or certification. If a health care provider has more than one taxonomy code associated with it, a health plan may prefer that the health care provider use one over another when submitting claims for certain services. It is strongly recommended that the taxonomy be populated in PRV segments for all applicable claims that you are filing. Refer to the CMS website for a listing of codes, www.wpc-edi.com/taxonomy.

Anthem Blue Cross and Blue Shield - East Region

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837 Professional Claim Header The 837 Claim Header identifies the start of a transaction, the specific transaction set, and its business purpose. Also, when a transaction set uses a hierarchical data structure, a data element in the header, BHT01 (Hierarchical Structure Code) relates the type of business data expected within each level. The following table indicates the specific values of the required header segments and data elements for East Region processing.

837 Professional Health Care Claim—Header IG

Segment

Reference Designator(s) ST Transaction Set Header P.61 ST ST01 Transaction Set Transaction Set Header Identifier Code ST02 Transaction Set Control Number Beginning of Hierarchical Transaction P.62 BHT BHT06 Beginning of Transaction Type Hierarchical Code Transaction Loop ID 1000B—Receiver Name P.72 NM1 NM103 Receiver Name Last Name or Organization Name NM109 Identification Code

Anthem Blue Cross and Blue Shield - East Region

Value

Definitions and Notes Specific to East Region

837

837 - Health Care Claim

(Identical to SE02)

Unique number assigned by the sender and generated by the sender's system.

CH

All submissions recognized as chargeable.

ANTHEM BLUE CROSS AND BLUE SHIELD 00060 00680 00770

Receiver Name

00060 - Connecticut 00680 - Maine 00770 - New Hampshire

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837 Professional Claim Detail The 837 Detail level has a hierarchical level (HL) structure based on the participants involved in the transaction. The three levels for the participant levels include:

1

1)

Information Source (Billing/Pay-to Provider)

2)

Subscriber (Can be the Patient when the Patient is the Subscriber)

3)

Dependent (Patient when the Patient is not the Subscriber)

837 Claim Detail: Billing/Pay-to Provider Hierarchical Level The first hierarchical level (HL) of the 837 Claim Detail, Billing/Pay-to Provider HL, identifies the original entity who submitted the electronic claim to the destination payer.

837 Professional Health Care Claim—Detail Billing/Pay-to Provider Hierarchical Level IG

Segment

Reference Value Designator(s) Loop ID 2000A—Billing/Pay-to Provider Hierarchical Level P.76 PRV PRV01 BI Provider Code Billing/Pay-to Provider (Provider PRV03 Specialty Reference Taxonomy Code) Information Identification P.78

Definitions and Notes Specific to East Region BI - Billing When using NPI, enter the taxonomy code that applies to the service on the claim that you are filing (NOTE to Clearinghouses - DO NOT DEFAULT). USD - US Dollars

CUR02 USD CUR Currency Code Foreign Monetary amounts recognized in US dollars Currency only. Information Loop ID 2010AA—Billing Provider Name XX - National Provider Identifier P.81 NM1 NM108 XX 24 - Employer's Identification Number Billing Provider ID Code Qualifier 24 34 - Social Security Number Name 34 • NPI ('XX') for Non-Exempt providers NM109 (Billing Provider • Tax ID ('24') and SSN ('34') for Exempt Identification Primary ID No.) providers Code P.84 N3 For correct claim adjudication, Anthem requests the address of N301, 302 Billing Provider Address the physical location at which services were rendered , not Information Address from where the services were billed. P.87 REF 1B - Blue Shield Provider Number REF01 1B EI - Employer's Identification Number Billing Provider Reference ID EI SY - Social Security Number Secondary Qualifier SY Identification • Provider's Tax ID ('EI') REF02 (Billing Provider • Provider's Social Security No. ('SY') Reference Additional • Assigned Provider No. ('1B') - for Exempt Identification Identifier) Providers

Anthem Blue Cross and Blue Shield - East Region

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837 Claim Detail Subscriber Hierarchical Level The second hierarchical level (HL) of the 837 Detail is the Subscriber HL. It is strongly recommended that each interchange (ISA-IEA envelope) be limited to 3000 claims for processing efficiency.

837 Professional Health Care Claim—Detail Subscriber Hierarchical Level IG

Segment

Reference Value Designator(s) Loop ID 2000B—Subscriber Hierarchical Level P.105 SBR SBR01 P, S, T Subscriber Payer Information Responsibility Sequence Number Code SBR09 BL Claim Filing MC Indicator Code

Definitions and Notes Specific to East Region Usage of 'S' or 'T' must be accompanied by information populated in Loop 2320.

BL - BlueCross/ Blue Shield MC - Medicaid (BlueCare Family Plan) If value BL or MC is not used, a Level 2 Status Report will be returned to the submitter.

Loop ID 2010BA—Subscriber Name P.112 NM1 Applies to: Format Explanation NM109 Enter one of the Subscriber Identification following formats: Name Code ***ALL ALPHA CHARACTERS MUST BE IN UPPERCASE LETTERS. J (uppercase) followed by 9-position BlueCare (J099999990) numeric subscriber ID code. Family Plan e.g. J123456789 R (uppercase) followed by 8-position FEP (R99999999) numeric subscriber ID code. e.g. R12345678 Enter the ID Number exactly as it appears on the front All other of the ID card, including ANY PREFIX. products 3-character alpha prefix (uppercase) (XXX999999) followed by 6-position numeric e.g. PTH123456 subscriber ID code. 3-character alpha prefix (uppercase) (XXX9999999) followed by 7-position numeric e.g. TSJ1234567 subscriber ID code. 3-character alpha prefix (uppercase) (XXX99999999) e.g. PTH12345678 followed by 8-position numeric subscriber ID code. 3-character alpha prefix (uppercase) (XXX999999999) e.g. YTA123456789 followed by 9-position numeric subscriber ID code. 3-character alpha prefix (uppercase) (XXX9999999999) e.g. OCI1234567899 followed by 10-position numeric subscriber ID code. (XXX99999999999) 3-character alpha prefix (uppercase) followed by 11-position numeric e.g. subscriber ID code. YGC12345678901 3-character alpha prefix (uppercase) (XXX9999X99999) followed by 4-position numeric, 1e.g. character alpha, and 5-position XVG0000A11111 numeric subscriber ID code.

Anthem Blue Cross and Blue Shield - East Region

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837 Claim Detail Patient Hierarchical Level The third hierarchical level (HL) of the 837 Claim Detail is the Patient HL. It is strongly recommended that each interchange (ISA-IEA envelope) be limited to 3000 claims for processing efficiency. Enveloping

837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Designator(s) Loop ID 2010CA—Patient Name P.154 DMG DMG02 Patient Date Time Demographic Period Information Loop ID 2300—Claim Information P.160 CLM CLM01 Claim Claim Information Submitter's Identifier CLM02 Monetary Amount CLM05-3 Claim Frequency Type Code CLM08 Yes/No Condition or Response Code P.199 PWK PWK02 Claim Report Supplemental Transmission Information Code PWK05 ID Code Qualifier PWK06 Identification Code

P.205 AMT Patient Amount Paid

AMT01 Amount Qualifier Code AMT02 Monetary Amount P.216 REF REF02 Reference Original Reference No. Identification (ICN/DCN)

Anthem Blue Cross and Blue Shield - East Region

Value

Definitions and Notes Specific to East Region

(Patient Birth Date)

When the patient's date of birth falls after the patient's date of service (Loop 2400, DTP03), a Level 2 Status Report will be returned to the submitter.

(Patient Account Number)

ƒ Represents the Patient Control No. returned on the 835. ƒ Do not use special characters as part of value.

(Total Claim Charge Amount)

Value must equal the total amount of submitted charges for service lines in Loop 2400, SV102.

7, 8

'7' - Replacement (Replacement of Prior Claim) '8' - Void (Void/Cancel of Prior Claim)

(Benefits Assignment Indicator) BM

For National Accounts, an "N" value indicates benefits have not been assigned to the provider. Claim payment is sent to the member and not the provider. ƒ Supporting documentation and Attachment Face Sheet accepted by mail (BM) only within 7 calendar days of the electronic transmission otherwise the claim will be denied. ƒ Illegible information will delay processing.

AC

AC - Attachment Control Number

(Attachment Control Number)

ƒ Self-assigned number, max. 10 alphanumeric characters on the Attachment Face Sheet. ƒ Digits drawn from the left to match the Attachment with the appropriate electronically submitted claim. F5 - Patient Amount Paid

F5

(Patient Amount Paid)

Represents the Patient Amount Paid.

(Claim Original Reference Number)

• Must be submitted for frequency codes of '7' (replacement), '8' (void) in CLM05-3. • Represents the Original Claim Reference No. returned on electronic and paper remittances.

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837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Value Designator(s) Loop ID 2300—Claim Information (cont'd) P.228 REF REF02 (Medical Record Medical Reference Number) Record No. Identification HI01-2 HI05-2 (Diagnosis Code) P.254 HI HI06-2 Health Care HI02-2 HI03-2 HI07-2 Diagnosis HI04-2 HI08-2 Code

Definitions and Notes Specific to East Region ƒ Represents the Medical Record No. returned on the 835. ƒ Do not use special characters as part of value. Blue Shield claims are adjudicated based only on the primary diagnosis.

Industry Code

Loop ID 2310A—Referring Provider Name Referring Provider recognized 1) at the claim level and 2) for managed care only. XX - National Provider Identifier P.271 NM1 NM103, (NM104) (Referring 24 - Employer's Identification Number Referring Last (First) Name Provider Last 34 - Social Security Number Provider or Organization (First) Name) Name Name NM108 XX ID Code Qualifier 24 34 • NPI ('XX') for Non-Exempt providers NM109 (Referring Identification Provider Primary • Tax ID ('24') and SSN ('34') for Exempt providers Code Identifier) P.276 REF 1B - Blue Shield Provider Number REF01 1B 1G - Provider UPIN Number Referring Reference ID 1G EI - Employer's Identification Number Qualifier Provider EI SY - Social Security Number Secondary SY Identification REF02 • Provider's Tax ID ('EI') (Referring • Provider's Social Security No. ('SY') Reference Provider • Assigned Provider No. ('1B') and UPIN ('1G') - for Identification Secondary ID) Exempt Providers Loop ID 2310B—Rendering Provider Name Rendering Provider recognized at the claim level only. XX - National Provider Identifier P.278 NM1 NM108 XX 24 - Employer's Identification Number Rendering ID Code Qualifier 24 34 - Social Security Number Provider 34 • NPI ('XX') for Non-Exempt providers NM109 (Rendering Name • Tax ID ('24') and SSN ('34') for Exempt providers Identification Provider Code Identifier) P.283 REF 1B - Blue Shield Provider Number REF01 1B EI - Employer's Identification Number Rendering Reference ID EI SY - Social Security Number Provider Qualifier SY Secondary • Provider's Tax ID ('EI') REF02 (Rendering Identification Reference • Provider's Social Security No. ('SY') Provider • Assigned Provider No. ('1B') - for Exempt Identification Secondary Providers Identifier)

Anthem Blue Cross and Blue Shield - East Region

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837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Value Designator(s) Loop ID 2310D—Service Facility Location P.290 NM1 NM101 FA Service Entity Identifier Code Facility NM108 XX Location ID Code Qualifier 24 34 NM109 (Lab/ Facility Identication Code Primary ID)

Definitions and Notes Specific to East Region FA - Facility XX - National Provider Identifier 24 - Employer's Identification Number 34 - Social Security Number • NPI ('XX') for Non-Exempt providers • Tax ID ('24') and SSN ('34') for Exempt providers

P.296 REF 1A - Blue Cross Provider Number REF01 1A TJ - Tax ID Service Reference ID Qualifier TJ • Provider's Tax ID ('TJ') Facility REF02 (Laboratory • Assigned Provider No. ('1A') - for Exempt Location Reference or Facility Providers Secondary Identification Secondary Identification Identifier) Loop ID 2320—Other Subscriber Information When East Region is secondary , following data elements required for Coordination of Benefits (COB): P.303 SBR • Use of ‘S’ requires that primary payer information SBR01 P be present in Loop 2320. Other Payer Responsibility S • Use of ‘T’ requires that both primary and Subscriber Sequence Number T secondary payer information be present in Loop Information Code 2320. P.308 CAS Populate CAS segment with quantity, monetary amounts, and appropriate Claim Level adjustment reason codes 1 = deductible, 2 = coinsurance, 3 = copayment. Adjustments CAS02,5,8,11,14,17 (Adjustment Identifies the reason for claim being adjusted. Claim Adjustment Reason CAS03,6,9,12,15,18 (Adjustment Represents the amount being adjusted. Monetary Amount Amount) CAS04,7,10,13,16,19 (Adjustment Represents the units of service being adjusted. Quantity Quantity) P.317 AMT COB Payer Paid Amount must be populated for COB claims. D - Payor Amount Paid COB Payer AMT01 D Paid Amount Amount Qualifier Code Represents the Payer Paid Amount (Payer Paid AMT02 Monetary Amount Amount) AAE - Approved Amount P.318 AMT AAE AMT01 COB Amount Qualifier Code Approved Represents the Approved Amount AMT02 (Approved Amount Monetary Amount Amount) P.319 AMT COB Allowed Amount must be populated for COB claims. B6 - Allowed-Actual COB Allowed AMT01 B6 Amount Amount Qualifier Code Represents the Allowed Amount AMT02 (Allowed Monetary Amount Amount)

Anthem Blue Cross and Blue Shield - East Region

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837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Designator(s)

Value

Definitions and Notes Specific to East Region

Loop ID 2320—Other Subscriber Information (cont'd) When East Region is secondary , following data elements required for Coordination of Benefits (COB): F2 - Patient Responsibility - Actual P.320 AMT F2 AMT01 COB Patient Amount Qualifier Code Responsibility AMT02 Represents the Other Payer (Other Payer Patient Patient Responsibility Amount. Amount Monetary Amount Responsibility Amount) P.321 AMT AU - Coverage Amount AMT01 AU COB Covered Amount Qualifier Code Amount (Other Payer Covered Represents the Other Payer AMT02 Covered Amount. Monetary Amount Amount) P.322 AMT D8 - Discount Amount AMT01 D8 COB Discount Amount Qualifier Code Amount (Other Payer Discount Represents the Other Payer AMT02 Discount Amount. Monetary Amount Amount) P.323 AMT DY - Per Day Limit AMT01 DY COB Per Day Amount Qualifier Code Represents the Other Payer Per Limit Amount (Other Payer Per Day AMT02 Day Limit Amount. Monetary Amount Limit Amount) P.324 AMT F5 - Patient Amount Paid AMT01 F5 COB Patient Amount Qualifier Code Represents the Other Payer Paid Amount (Approved Amount) AMT02 Patient Paid Amount. Monetary Amount P.325 AMT T - Tax AMT01 T COB Tax Amount Qualifier Code Amount Represents the Other Payer Tax (Other Payer Tax AMT02 Amount. Monetary Amount Amount) P.326 AMT T2 - Total Claim Before Taxes AMT01 T2 COB Total Amount Qualifier Code Represents the Other Payer PreClaim Before AMT02 (Other Payer Pre-Tax Taxes Amount Monetary Amount Tax Claim Total Amount. Claim Total Amount) P.332 MOA MOA01 (Reimbursement Rate) Represents the Outpatient reimbursement rate, expressed as Medicare Percent a decimal. Outpatient Adjudication Information Loop ID 2330B—Other Payer Name P.349 DTP Represents when the primary DTP03 (Adjudication or payer made payment and is Claim Date Time Period Payment Date) recognized for processing Adjudication Coordination of Benefits. Date

Anthem Blue Cross and Blue Shield - East Region

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837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Value Definitions and Notes Designator(s) Specific to East Region Loop ID 2400—Service Line P.381 LX LX01 Accept up to 50 service lines per claim. Service Line Assigned Number P.383 SV1 When billing unlisted HCPCS (NOC codes), include the SV101-2 (Procedure drug and dosage at the service line in Loop 2400 NTE02 Professional Procedure Code Code) (Description). Report the corresponding NDC# in Loop Service 2410 LIN03. ƒ Maximum of 4 procedure modifiers accepted. SV101-3ʊ6 (Procedure Procedure Modifier 1-4) ƒ A value of ‘99’ is defined as “multiple modifiers”. Modifier ƒ Sum of service line charges must equal the Total Claim SV102 (Line Item Charge Amount in Loop 2300 CLM02. Monetary Charge ƒ Value cannot be less than zero, or greater than Amount Amount) $999,999.99. ƒ Accept values greater than or equal to zero, and up to SV103 MJ 9999. Unit or UN ƒ Report anesthesia time in units ('UN'). Measurement Code (Service Unit Accept values greater than or equal to zero, and up to SV104 9999. Quantity Count) SV105 (Place of For HMO/PPO claims, values for 1) assistant surgery, 2) Facility Code skilled nursing facility and 3) cardiac rehabilitation place Service Value of services accompanies facility code values (Loop Code) 2310D, Service Facility Location). 41, 42 P.391 SV5 Durable Medical Equipment Service P.416 DTP Date Service Date

SV505 Monetary Amount

(DME Purchase Price)

Ambulance services using values ’41’ and ‘42’ is submitted with a SV101-3 value greater than zero. Anthem defines the DME Purchase Price as the Manufacturer's Suggested Retail Price which does not include shipping/handling or tax.

A Level 2 Status Report will be returned to the submitter if value is: 1) prior to the patient’s Date of Birth (Loop 2010CA, DMG02) or 2) "From Date" precedes the "To Date." East Region accepts procedure text at the line level only. When billing unlisted HCPCS (NOC codes) in Loop 2400 P.467 NTE NTE02 (Line Note SV101-2 (Procedure Code), include the drug and Line Note Description Text) dosage. DTP03 Date Time Period

(Service Date)

For Medicare Private Fee for Service claims, submit the dates when the provider assumed/relinquished patient to/from post-operative care. Loop ID 2410—Drug Identification P.459 LIN (National LIN03 Drug Product/Service Drug Code) Identification ID

Anthem Blue Cross and Blue Shield - East Region

NDC# (without hyphens) corresponds to unlisted HCPCS (NOC codes) in Loop 2400 SV101-2, and the drug and dosage in Loop 2400 NTE02. Example: NDC# 12345-6789-10 is recognized as 12345678910.

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837 Professional Health Care Claim—Detail Patient Hierarchical Level IG

Segment

Reference Designator(s) Loop ID 2420E—Ordering Provider Name P.513 NM1 NM103, (NM104) Ordering Last (First) Name or Provider Organization Name Name NM108 ID Code Qualifier

Value

(Ordering Provider Last (First) Name) XX 24 34 NM109 (Order Provider Identification Code Primary Identifier) P.519 REF REF01 1B Ordering Reference ID Qualifier EI Provider SY Secondary REF02 (Ordering Identification Reference Provider Identification Secondary ID)

Definitions and Notes Specific to East Region The First and Last Name, or Organization Name of the Ordering Provider for radiology services is recognized. XX - National Provider Identifier 24 - Employer's Identification Number 34 - Social Security Number • NPI ('XX') for Non-Exempt providers • Tax ID ('24') and SSN ('34') for Exempt 1B - Blue Shield Provider Number EI - Employer's Identification Number SY - Social Security Number • Provider's Tax ID ('EI') • Provider's Social Security No. ('SY') • Assigned Provider No. ('1B') - for Exempt Providers

Loop ID 2430—Line Adjudication Information P.536 SVD SVD segment must be populated for COB claims. Matches Loop 2330B NM109 identifying Service Line SVD01 (Other Payer ID Other Payer. Adjudication Identification Code Code) (Service Line Paid Represents paid amount by the primary SVD02 payer. Monetary Amount Amount) HC - HCPCS Code HC SVD03-1 IV - HIEC Product/Service Code Product/Service ID IV ZZ - Mutually Defined Qualifier ZZ SVD03-2 (Procedure Code) Represents procedure code. Product/Service ID Represents procedure modifier, if applicable. SVD03-3, -4, -5, -6 (Procedure Product/Service ID Modifier) Qualifier (Paid Service Unit Represents paid units of service by the SVD05 primary payer. Quantity Count) P.540 CAS When Loop 2430 SVD02 service line amount differs from Loop 2400 SV102 total Line charge amount, the CAS segment must be populated with quantity, monetary Adjustment amounts, and appropriate adjustment reason codes. Identifies the reason for claim being adjusted. CAS02,5,8,11,14,17 (Adjustment Claim Adjustment Reason Code) Reason Code Represents the amount being adjusted. CAS03,6,9,12,15,18 (Adjustment Monetary Amount Amount) Represents the units of service being CAS04,7,10,13,16,19 (Adjustment adjusted. Quantity Quantity) P.548 DTP Line Adjudication Date

DTP03 Date Time Period

Anthem Blue Cross and Blue Shield - East Region

(Adjudication or Payment Date)

Represents when the primary payer made payment and is recognized for processing Coordination of Benefits.

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Enveloping EDI envelopes control and track communications between you and Anthem. One envelope may contain many transaction sets grouped into functional groups. The envelope consists of the following:

Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA)

837 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS)

Envelope

Envelope

Envelope

Transaction Set Header (ST)

Header Detail

Transaction Set Trailer (SE) Functional Group Trailer (GE) Interchange Control Trailer (IEA)

Anthem Blue Cross and Blue Shield - East Region

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837 Envelope Control Segments – Inbound 1

837 Health Care Claim Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it clearly identifies the sender, receiver, date, time, and interchange control number. Anthem requests all data in the ISA-IEA segment to be entered in UPPER CASE.

837 Professional Health Care Claim Interchange Control Header (ISA) Segment

ISA Interchange Control Header

Reference Designator(s)

Value

ISA01 00 Auth Info Qualifier ISA02 (10 Spaces) Authorization Info ISA03 00 Security Info Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Rec ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control Standards Identifier ISA12 Interchange Control Version Number ISA13 Interchange Cntrl No.

00 - No Authorization Information Present Enter 10 positions. 00 - No Security Information Present

(10 Spaces)

Enter 10 positions.

ZZ

ZZ - Mutually Defined

(Submitter ID)

ƒ Format - Fixed length of 15 positions, alphanumeric. ƒ Left-justified followed by spaces. ƒ Identical to GS02. ZZ - Mutually Defined

ZZ

(YYMMDD)

ƒ ANTHEM - Anthem Plans ƒ Left-justified followed by spaces. Value must be a valid date in YYMMDD format.

(HHMM)

Value must be a valid time in HHMM format.

U

U - U.S. EDI Community of ASC X12, TDCC, and UCS

00401

00401 - Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 ƒ Format - Fixed length 9 positions, numeric. ƒ Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. ƒ Right-justified, filled with leading zeroes. ƒ Identical to IEA02. 0 - No Acknowledgment Requested 1 - Interchange Acknowledgment Requested Submitter ID must be approved to submit production data (P - Production Data; T - Test Data). ƒ X - 1 character contained in Basic or Extended Character set. ƒ Value must not equal A-Z, a-z, 0-9, "space", and special characters which may appear in text data (i.e., hyphen, comma, period, apostrophe).

ANTHEM

(Assigned by Sender)

ISA14 0, 1 Ack Requested ISA15 P, T Usage Indicator ISA16 (X) Component Element Separator

Anthem Blue Cross and Blue Shield - East Region

Definitions and Notes Specific to Anthem

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2

837 Health Care Claim Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Anthem requests that all data in the GS-GE segment be entered in UPPERCASE.

837 Professional Health Care Claim Functional Group Header (GS) Segment

GS Functional Group Header

Reference Designator(s) GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code

GS04 Date GS05 Time GS06 Group Control Number

Value

Definitions and Notes Specific to Anthem

HC

HC - Health Care Claim (837)

(Submitter ID)

ANTHEMCT ANTHEMME ANTHEMNH 20012 (CCYYMMDD)

ƒ Format - 2-15 positions, alphanumeric. ƒ Left-justified with no trailing zeroes or spaces. ƒ Identical to ISA06. Routing of batched transactions to: ANTHEMCT - CT BCBS Plan ANTHEMME - ME BCBS Plan ANTHEMNH - NH BCBS Plan 20012 - Machigonne Benefits Value must be a valid date in CCYYMMDD format.

(HHMM)

Value must be a valid time in HHMM format.

(Assigned by Sender)

ƒ Format - 1-9 positions, numeric. ƒ Unique value greater than zero and not used in any HIPAA transmission within last 365 calendar days. ƒ Left-justified with no trailing zeroes or spaces. ƒ Identical to GE02. X - Accredited Standards Committee X12

X GS07 Responsible Agency Code GS08 Version / Release / 004010X098A1 Industry Identifier Code

Operationally used to identify the transaction: 004010X098A1 - 837 Professional Claim

NOTE. Critical Batching and Editing Information. **Transactions must be batched in separate functional group by Application Receiver’s Code (GS03). ***Group Control Number (GS06) may not be duplicated by submitter. Files containing duplicate or previously received group control numbers will be rejected.

Anthem Blue Cross and Blue Shield - East Region

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837 Health Care Claim Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information.

837 Professional Health Care Claim Functional Group Trailer (GE) Segment

GE Functional Group Trailer

4

Reference Designator(s) GE01 Number of Transaction Sets Included GE02 Group Control Number

Value

(Total Number of Transaction Sets in Functional Group or Transmission) (Control Number)

Definitions and Notes Specific to Anthem ƒ Format - 1-6 positions, numeric. ƒ Left-justified with no trailing zeroes or spaces.

ƒ Format - 1-9 positions, numeric. ƒ Left-justified with no trailing zeroes or spaces. ƒ Identical to GS06.

837 Health Care Claim Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment).

837 Professional Health Care Claim Interchange Control Trailer (IEA) Segment

IEA Interchange Control Trailer

Reference Designator(s) IEA01 Number of Included Functional Groups IEA02 Interchange Control Number

Anthem Blue Cross and Blue Shield - East Region

Value

(Number of Functional Groups GS/GE Pairs in Interchange) (Control Number)

Definitions and Notes Specific to Anthem ƒ Format - 1-5 positions, numeric. ƒ Left-justified with no trailing zeroes or spaces. ƒ Format - Fixed length 9 positions, numeric. ƒ Unique value greater than zero. ƒ Identical to ISA13.

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