Gateway EDI ANSI Professional Claims Companion Document ASC X12N-837 004010X098 ASC X12N-837 004010X098A1

Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together

The Health Insurance Portability and Accountability Act (HIPAA) requires that all health insurance payers in the United States comply with the Electronic Data Interchange (EDI) standards as established by the Secretary of Health and Human Services. For claim transactions, these standards of compliance have been published as ANSI X12N-837 Implementation Guides. The following information is intended to supplement the ANSI X12N-837 Professional Claims Implementation Guide. The use of this document is solely for the purpose of clarification.

Envelope Information: Recommended Data Element Delimiter Recommended Segment Delimiter Recommended Component – Element Delimiter

* (Asterisk) ~ (Tilde) : (Colon)

Element ISA05 – Interchange ID Qualifier ISA06 – Interchange Sender ID

Instruction Report ZZ Gateway EDI assigned site number. This number is four digits in length, and should be followed by trailing spaces up to the required length of 15 bytes for this element. Report ZZ Report 431420764000000 The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02. This number should also be unique to every file. Any files received with the same control number in ISA13 will be denied as duplicate files. Gateway EDI assigned site number. This number is four digits in length. Report 431420764 Version 4010 – 004010X098 Version 4010A1 – 004010X098A1

ISA07 – Interchange ID Qualifier ISA08 – Interchange Receiver ID ISA13 – Interchange Control Number

GS02 – Application Sender’s Code GS03 – Application Receiver’s Code GS08 – Version/Release/Industry Identifier Code

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Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together General Claim Transaction Details:

LOOP 2000A

SEGMENT/ ELEMENT CUR02

2000A 2310B

PRV02

2010BB

NM109

2010AA, NM108, NM109 2010AB, REF01, REF02 2310A, 2310B, 2310C, 2310D, 2310E 2010AA REF01, REF02

COMMENTS Must send a country code if not in the US for any address where the country code would normally be situational. Default value = USA The Provider Taxonomy Code is to be reported in the PRV02 (Qualifier ZZ) in the 2310B loop. If no rendering loop is present, then it should be reported in the 2000A loop. The Health Care Provider Taxonomy Code List can be accessed at http://www.wpc-edi.com. Gateway EDI requires a five digit Payer ID for all claims. For paper claims, use Payer ID “00010” The National Provider Identification (NPI) is to be reported in the NM108/NM109 (Qualifier XX). Either the EIN or SSN of the provider must also be reported in the corresponding REF01/REF02 of this loop (Qualifier 24-EIN, Qualifier 34-SSN). If you will be sending the billing provider secondary ID, report it in the REF01/REF02 of this loop. When required, payer specific submitter ID’s should also be sent as an additional REF01/REF02 in the 2010AA loop using qualifier “FH”. Gateway EDI Assigned Doctor ID is situationally required and should be reported with a qualifier of G5 when reported.

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Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together 2010AA, N404 2010AB, 2010BA, 2010BB, 2010BC, 2010CA, 2310D, 2330A, 2420C, 2420E 2000B PAT03 2000C

Send a country code if not in the US for any address where the country code would normally be situational. Default value = US

2000C

PAT04

Student Status Code is still used by many payers. During early implementation, it may be situationally necessary to report this data element in order to prevent claims from being rejected. 4010A1 – This field is NOT USED.

2400

SV106

Type of Service Code is still used by many in their current claims adjudication systems. During early implementation, it may be necessary to report this data element in order to prevent claims from being rejected.

Employment Status Code is still used by many payers. During early implementation, it may be situationally necessary to report this data element in order to prevent claims from being rejected. 4010A1 – This field is NOT USED.

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Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together

Coordination of Benefits (COB) Claims including coordination of benefits information (COB) may be submitted electronically through Gateway EDI. Hints and tips regarding how to populate COB segments are included below for your reference. Loop Usage Hints for Primary & Secondary claims containing COB: Destination Payer – The destination payer is referred to here as the current payer you are submitting your claim to for payment. The destination payer’s information is located in Loop ID-2010BB. In addition, any destination payer specific claim information (e.g., referral number) is located in the 2300 loop. All provider identifiers in the 2310 and 2420 loops are specific to the destination payer. Additional Payers – Additional payers are referred to here as any other payer that may eventually have a responsibility in paying this claim. Loop ID-2320 indicates an additional payer responsible for the claim. This loop does not include any information for the destination payer. Loop ID-2320 must contain the following fields: Page 5 3/18/2009

Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together

• Claim level adjustments, if this particular payer has already considered the claim. • Other subscriber demographics (e.g., birth date, gender) • Amounts obtained from the corresponding payer’s 835 (electronic remit), if this particular payer has already considered the claim. • Other payer information, including payer name and payer identifier. Payer address optional. • Assignment of benefits indicator, specific to this particular payer. • Patient signature indicator Loop ID-2330 also contains subscriber and payer information that is specific to the payer identified in Loop ID- 2320. How to Properly Swap COB Payer Information as Payments are Received: As the claim moves from payer to payer, the destination payer’s information in Loop ID-2000B and Loop ID-2010BB must be exchanged with the next payer’s information from Loop ID2320/2330. Submitting a Claim for the First Destination Payer: 2000B/2010BB First (usually the primary) payer 2320/2330 Second payer Submitting a Claim for the Second Destination Payer: 2000B/2010BB Second (usually the secondary) payer 2320/2330 Primary payer

COB at the Service Line Level: Loop ID-2430 is an optional loop that can occur one or more times for each service line. As each payer adjudicates the service lines, occurrences may be added to this loop to explain how the payer adjudicated the service line. Loop ID-2430 contains the following: • ID of the payer who adjudicated the service line • Amount paid for the service line • Procedure code upon which adjudication of the service line was based. This code may be different than the submitted procedure code. (This procedure code also can be used for unbundling or bundling service lines.) Page 6 3/18/2009

Professional Claims Companion Document ASC X12N – 837 004010X098 ASC X12N – 837 004010X098A1

Gateway EDI Where Technology and Service Come Together

• Paid units of service • Service line level adjustments • Adjudication date To enable accurate matching of billed service lines with paid service lines, it is required that the payer return the original billed procedure code(s) and/or modifiers in the 835 if they are different from those used to pay the line. In addition, if a provider includes line item control numbers at the 2400 level (REF01 = 6R) then payers are required to return this in the corresponding 835.

Auto-generated Secondaries: If you submit electronic claims to Gateway EDI and we also retrieve your electronic remits (835’s), you may be eligible for our Autogenerated Secondaries solution. Upon request, we can auto-generate secondary claims for you when both the primary claim and the primary payer’s electronic remit are transmitted through Gateway EDI. The primary claim will simply need to include secondary payer information, including appropriate secondary payer ID, secondary provider ID’s, and any applicable subscriber information for that secondary payer. Clients using this option will not be responsible for reporting or retrieving any payment or adjustment information from the corresponding 835. For more information on this solution, contact our Customer Service Department at (800) 556-2231. Gateway EDI 501 N Broadway, 3rd Floor Saint Louis, MO 63102

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