HealthSmart Benefit Solutions HIPAA

COMPANION GUIDE

HealthSmart Benefit Solutions HIPAA COMPANION GUIDE

602 Virginia Street East Charleston, WV 25301

Version 2.0 Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HIPAA Companion Guide

Preface This Companion Guide to the ASC X12N Implementation Guides adopted under HIPAA, clarifies and specifies the data content being requested when data is transmitted electronically to / from HealthSmart Holdings, Inc. Transmissions based on this companion document, used in tandem with the X12N Implementation Guides, are compliant with both X12 syntax and those guides.

This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under the HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HIPAA Companion Guide

1 Introduction This guide is provided to assist Providers and their Agents in the process of exchanging Electronic Data Interchange (EDI) transactions with HealthSmart Benefit Solutions.

1.1 Scope This Companion Guide was created for HealthSmart’s Trading Partners to supplement the HIPAA X12 Implementation Guides. It contains supplemen tal instructions for the following: Data content, codes, business rules, and characteristics of the transactions that are sent to / received from HealthSmart. Technical requirements and transmission options Information on testing procedures to assist each HealthSmart Benefit Solutions Trading Partner with the testing process

1.2 Overview These specifications are to be used in conjunction with the National Electronic Data Interchange Transaction Set Implementation Guides, which can be obtained from the Washington Publishing Company at WPC-EDI.com. The HealthSmart Benefit Solutions.Companion Guide provides supplemental information specific to HealthSmart as permitted within the structures of the HIPAA transaction sets. Specifications may be updated as necessary to reflect changes in the HIPAA standard, or changes in HealthSmart’s requirements.

HIPAA does not mandate that only X12N transactions can be used to exchange healthcare data. Any Provider may continue to submit paper claims and receive a paper remittance advice. However, any Provider who wishes to submit claims electronically or receive an electronic remittance advice will be required to adhere to the HIPAA transaction and code set standards.

Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HI PAA Companion Guide

1.3 Working with HealthSmart’s EDI Any business entity that will exchange data with the X12 EDI Transactions directly with HealthSmart will be required to complete a Trading Partner Agreement (TPA) with HealthSmart Benefit Solutions.

Original signed documents must be mailed to: HealthSmart Benefit Solutions Attn: EDI Coordinator 602 Virginia Street, East PO Box 3043 Charleston, WV 25331-3043

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Currently, HealthSmart’s direct Trading Partners for ANSI X12 transactions are Clearinghouses. Please cont act our EDI Coordinator to get updated lists of the clearinghouses that exchange EDI X12 transactions with HealthSmart.

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Assignment of the Trading Partner ID and scheduling for testing is done individually as Trading Partners are added to the above referenced list. Please Contact our EDI Coordinator to determine Trading Partner ID and to schedule testing.

Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HIPAA Companion Guide

2 837 Technical Specifications / Business Rules These Technical Specifications provide information specific to HealthSmart edits and requirements.

Item Loop #

Segment Name

Language HealthSmart will convert all lower case characters submitted on an inbound 837 to upper case when sending data to our legacy system.

2

All dates that are submitted on an incoming 837 claim transaction must 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. HealthSmart prefers only one transaction type (records group) per interchange (transmission): a submitter should only submit one GS-GE (Functional Group) within an ISA-IEA (Interchange)

4

HealthSmart can receive one or more ST-SE (Transaction Set) within a GS-GE (Functional Group)

5

Interchange Control Header

6 7

We suggest retrieval of the Unsolicited Claim Status transaction on the first business day after the claim file is submitted . 2010AA 2010AB

8

Use your Submitter ID agreed upon by you (the submitter) and HealthSmart followed by the necessary spaces to meet the minimum / maximum data element requirement of 15 bytes in ISA06 (the Interchange Sender ID).

2310B 2000A (PRV01) 2010AA

Last Edited: 7/24/2009

Pay To Provider

The Bill to /Pay To Provider number, Name, Address, including zip are required fields by HealthSmart. The same data elements are required if the Pay-to loop is sent.

Rendering Provider

On Professional & Dental Claims, Rendering provider Name is a required field for HealthSmart. We will accept only one rendering provider per claim. Please do not put Rendering Provider Names on the service lines (2420A). Any values in the 2420A loop will not be used in processing.

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HealthSmart HIPAA Companion Guide *EXCEPTIONS* - The only exception to this requirement is when the billing provider and the rendering provider are the same entity/person. In that scenario, the 2000A PRV segment must be provided. The 2310B loop should not be sent in the scenario, per HIPAA requirements.

2010AB

9

2310D 2000A (PRV01)

Service Facility

*EXCEPTIONS* - When the 2000A PRV segment is provided, the 2310D loop is not necessary, per HIPAA requirements. Also, if the place of service code is 12 (HOME), then the Service Facility Address is not required.

2010AA 2010AB

10

2310

11 12

2300

On Professional Claims, the Service Facility Address and Zip code are required fields for HealthSmart.

Attending Provider

On Institutional Claims, one of the following fields is required by HealthSmart Benefit Solutions : Attending Physician Name, Other Physician name, or Operating Physician name.

Provider Taxonomy

Provider Taxonomy data elements are required for Healthsmart’s claims adjudication process.

Health Care Diagnosis

On Institutional claims Up to (15) Diagnosis Codes may be sent. Principal, Admitting and E-Code may come in one (1) HI segment, and up to (12) other diagnosis codes may be sent in a second HI segment. On Professional Claims up to eight diagnosis codes per claim may be sent: however the last four diagnosis codes will not be considered in processing.

13

2300

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Health Care Diagnosis

Diagnosis codes have a maximum size of five (5) bytes. HealthSmart does not accept decimal points in diagnosis codes.

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HealthSmart Benefit Solutions HIPAA Companion Guide

3 Acknowledgements and / or Reports HealthSmart issues the following to indicate the acceptance/rejection of files and claims into the claims processing system:

File Acknowledgement – Use of 997 997 File Acknowledgement Report: HealthSmart Benefit Solutions supports the Functional Acknowledgment Transaction Set (997), and uses it as an acknowledgement of the incoming 837 file. HealthSmart returns the 997 as once initial processing of 837 file ends. For this reason, there will be a delay between receipt of the claims file and return of the 997 transactions. The submitter should review the 997 to verify that the file will be processed.

Response Reports The 277 Unsolicited Claim Status, as described in Section 2.6.2 of the Implementation Guide, is currently not a HIPAAmandated transaction. HealthSmart Holdings, Inc. will send the Emdeon (formerly WebMD/Envoy) Unsolicited Status Message transaction to report the status of claims received, until the ANSI X12 277 Unsolicited Claims Status transaction is available. Please refer to Emdeon’s Companion guide for details regarding this transaction. This transaction will be generated daily and sent back to the Trading Partner who sent incoming claim.

Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HIPAA Companion Guide

4 Current Claim Status Response Reasons The following reason codes are sent to our trading partners via the Emdeon Claim Status Transaction:

USM Code BF 86 8U 585 67 510 523 8L 80 QH 80 5V 20 20 30 4N

Accept/Reject Reject Reject Reject Reject Reject Reject Reject Reject Reject Reject Reject Reject Accept Accept Accept Accept

Description of Code Invalid or missing member number Invalid provider information Invalid or missing CPT OR HCPCS code * Invalid or missing anesthesia minutes Invalid or missing admitting diagnosis code Invalid or Incorrect Subscriber Date of Birth Number of service lines limit (50-HCFA/Dental, 99-UB92) Member Not Active Invalid or Missing Company Invalid or Missing Rendering/Service Facility Invalid or Missing Date of Service Submission of a duplicate claim Acknowledges Receipt of Claim/Encounter Referral/Authorization Accepted for Processing Predetermination is on File, Awaiting Completion

*NOTE – for 8U reject code, if no CPT4 code is sent and the revenue code falls between 960 And 989, the claim will be rejected.

Last Edited: 7/24/2009

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HealthSmart Benefit Solutions HIPAA Companion Guide

5 Contact Information (e) general information: [email protected] (e) technical support: [email protected]

Last Edited: 7/24/2009

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