835 Companion Guide - First Health

1 835 companion guide Introduction The Health Insurance Portability and Accountability Act (HIPAA) requires Health insurance payers in the United States to comply with the EDI standards for Health care as established by the Secretary of Health and Human Services if the provider wishes to submit certain types of healthcare transactions electronically. HIPAA. does not mandate providers to become electronic submitters; it simply describes the content and format of the information you (the provider of care) must supply. This ANSI X12N implementation Guide has been established as the standards of compliance for remittance of the Claim Payment Advice. First Health is providing the following information to serve only as a Companion document to the HIPAA ANSI X12N 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. This Companion document supplements, but does not contradict any requirements in the X12N.

2 Implementation Guide . Additional Companion documents/trading partner agreements will be developed for use with other HIPAA standards, as they become available. In the event a PPO agreement established between you and First Health requires the use of a situational data element, we will mutually agree to the most appropriate location on the ANSI transaction for this information. Additional information on the Final Rule for Standards for Electronic Transactions can be found at The HIPAA. Implementation Guides can be accessed at Purpose First Health will use the 835 Claims Payment Advice transaction set to communicate the results of claim adjudication and/or claim predetermination for benefits only upon written request from the provider using the Request Authorization contain in this Companion Guide . First Health will remit funds to the provider of care via a paper check. Electronic Funds Transfer will be available to First Health Network providers later in 2004. Rev 01/05 1. Special Notes 1.

3 Providers must specifically request an 835 themselves or via their clearinghouse. First Health will not automatically create an 835 in response to an 837. 2. If the provider submits electronically, the First Health EDI group maintains the clearinghouse source for the 837 and will deliver an 835 (if requested) back to the sender via the sender. 3. First Health 835 electronic remittance will be at a Provider Tax ID. Number (TIN) level only. Provider groups must understand that an 835. request will generate 835's for any provider billing using that TIN. Further, the provider will sign First Health 's authorization, which includes an acknowledgement that the requesting provider becomes responsible for coordinating distribution of the data in accordance with HIPAA privacy standards. 4. First Health is not establishing direct connections with any provider of care in 2003. Following successful implementation of the HIPAA. standards in October 2003, First Health will consider direct connections with preferred providers that generate a high volume of bills.

4 Rev 01/05 2. Authorization Form for 835 Remittance Advice First Health and Mail Handlers I,_____, hereby request to receive the 835 Electronic Remittance Advice for me and any other provider who uses the Tax ID number _____. I have the authority to make this request on behalf of the tax ID billing group and will assume responsibility for delivering the transactions to individual providers using this Tax ID in accordance with HIPAA privacy requirements concerning protected Health information (PHI). _____ _____. Requestor Name (please print) Requestor Signature _____. Tax ID. _____. 1099 Name associated with Tax ID (please print). Please send the completed document and attach a copy of the W-9 to WebMD Enrollment at or fax to (615) 885-3713. For further information regarding the above form please contact 800-813-0397, option 4. Rev 01/05 3. ANSI 835 File Information 835 Loop 835 Segment 835 Element Comments ISA ALL Determined between First Health and Clearinghouse GS ALL Determined between First Health and Clearinghouse ST ST01 Determined between First Health and Clearinghouse BPR BPR01 Remittance Information Only.

5 BPR02 Total Actual Provider Payment Amount BPR03 Credit amount or also to indicate that this is a check "ACH" if electronic check BPR04 "CHK" for paper check "CCP" for separate advise and payment BPR05 "CTX" for EFT included BPR06 ABA Routing Number qualifier BPR07 Payers Banks ABA number BPR08 Demand Deposit BPR09 Payers Bank Account Number BPR10 Payers TIN. Always preceded by a "1". BPR12 ABA Routing Number qualifier BPR13 Provider Bank's ABA Number BPR14 Demand Deposit BPR15 Providers Bank Account Number BPR16 Check issue date TRN TRN01 Check / EFT trace number qualifier EFT Trace Number: YJJJ nnnnnn Y = Last digit of year JJJ = Julian date TRN02 n's = running serial number TRN03 Payers TIN. Always preceded by a "1". Entity identifier code. 1000A N1 N101 PR = Payer N102 Payer's Name / Fund Name N3 N301 Payer's Address Line 1. N302 Payer's Address Line 2. N4 N401 Payer's City name N402 Payer's State N403 Payer's Zip PER PER01 Payer's Claim Office PER02 Payer's Contact Name Communications Number Qualifier PER03 TE = Telephone PER04 Payer's Claims Office / Customer Service phone number Entity identifier code.

6 1000B N1 N101 PE = Payee N102 Provider Name Identification Code Qualifier N103 FI = Provider FTIN. N104 Provider's FTIN. 1000B N3 N301 Provider Address Line 1. N302 Provider Address Line 2. Rev 01/05 4. 835 Loop 835 Segment 835 Element Comments 1000B N4 N401 Provider City N402 Provider State N403 Provider Zip Patient Control Number assigned by the provider. Can be 2100 CLP CLP01 obtained from inbound 837 - CLM01. Cross-reference table needs to be built. Use the EDI status CLP02 code definitions - refer to X091 HIPAA Implementation Guide CLP03 Sum of all submitted charges at the line level. CLP04 Claim payment amount CLP05 Patient responsibility Amount CLP06 Obtained from 837 - SBR09. CLP07 First Health Claim Control Number CLP08. CLP09. CLP11. CLP12. CLP13. Claim adjustment group code. PR - patient responsibility. 2100 CAS CAS01 CR - Correction and reversal CAS02 Claim adjustment reason code. CAS03. CAS04 Adjustment quantity CAS05. CAS06. CAS07. CAS08. CAS09. CAS10. CAS11. CAS12.

7 CAS13. CAS14. CAS15. CAS16. CAS17. CAS18. CAS19. 2100 NM1 NM101 Entity identifier code - Patient NM102 Entity type qualifier - Person NM103 Patient last name NM104 Patient First name NM108 ID code qualifier. Patient SSN. NM109 Patient's SSN. 2100 NM1 NM101 Entity identifier code - Insured or the Subscriber NM102 Entity type qualifier - Person NM103 Employee last name NM104 Employee First name NM108 ID code qualifier - Employee SSN. NM109 Employee SSN. Rev 01/05 5. 835 Loop 835 Segment 835 Element Comments 2110 SVC SVC01-01. SVC01-02. SVC01-03. SVC01-04. SVC01-05. SVC01-06. SVC02 Line item charge amount SVC03 Line payment amount SVC04. SVC05. SVC06-1. SVC06-2. SVC06-3. SVC06-4. SVC06-5. SVC06-6. SVC07. 2110 DTM DTM01. DTM02. Claim adjustment group code. PR - patient responsibility. 2110 CAS CAS01 CR - Correction and reversal CAS02 Claim adjustment reason code CAS03. CAS04. CAS05. CAS06. CAS07. CAS08. CAS09. CAS10. CAS11. CAS12. CAS13. CAS14. CAS15. CAS16. CAS17. CAS18. CAS19. 2110 REF REF01.

8 REF02. PLB PLB01. PLB02. PLB03-01. PLB03-02. PLB04. PLB05-01. PLB05-02. Rev 01/05 6. 835 Loop 835 Segment 835 Element Comments PLB06. PLB07-01. PLB07-02. PLB08. PLB09-01. PLB09-02. PLB10. PLB11-01. PLB11-02. PLB12. PLB13-01. PLB13-02. PLB14. SE SE01 Determined between First Health and Clearinghouse SE02 Determined between First Health and Clearinghouse GE Determined between First Health and Clearinghouse IEA Determined between First Health and Clearinghouse Rev 01/05 7.