Provider EDI Reference Guide - Highmark

1 Highmark is a registered mark of Highmark EDIR eference GuideHighmark EDI OperationsApril 5, 2010**This page left blank intentionally.**April 5, 20103 Table of ContentsChapter 1 Supported EDI Transactions.. Real-Time Transaction Capability.. Real-Time Technical Connectivity Specifications.. Real-Time Claim Adjudication and Estimation .. General Requirements and Best Practices .. 16 Chapter 2 General Information192 Contact Information .. System Operating Hours.. Provider Data Services .. Audit Procedures .. Valid Characters in Text Data (AN, string data element type) .. 21 Chapter 3 Security Confidentiality .. Authorized Release of Information .. 23 Chapter 4 Authorization Where to Get Enrollment Forms to Request a Trading Partner ID Receiving 835 Transactions Generated from the Payment Cycle (Batch) .. Adding a New Provider to an Existing Trading Partner.

2 Deleting Providers from an Existing Trading Partner .. Reporting Changes in Status .. 26 HighmarkTable of ContentsProvider EDI Reference Guide4 April 5, Out of State Providers.. 26 Chapter 5 Testing Web Based .. Highmark Transactional Testing .. Real-Time 837 Claim Estimation Demonstration Process .. 30 Chapter 6 Dial-Up / Asynchronous File Transfer .. Dial-Up Command Prompt Option .. Internet .. Internet File Transfer Protocol (FTP) through eDelivery .. Internet/Real-Time (HTTPS- Hypertext Terminal Protocol Se-cure) .. 36 Chapter 7 Transmission General Information .. Delimiters .. Data Detail and Explanation of Incoming ISA to Highmark .. 42 ISA Interchange Control Header (Incoming).. Data Detail and Explanation of Outgoing ISA from Highmark .. 43 ISA Interchange Control Header (Outgoing).. Outgoing Interchange Acknowledgment TA1 Segment.

3 Outgoing Functional Acknowledgment 997 Transaction.. 45 Chapter 8 Professional Claim (837P) General Information and Guidelines for Submitting an 837P .. Patient with Coverage from Another Blue Cross Blue Shield Plan .. KHP Central Out-of-Area Claims .. First Priority Life Insurance Company (FPLIC) Out-of-Area Claims.. Independence Administrators Out-of-Area Claims .. 52 HighmarkProvider EDI Reference GuideTable of ContentsApril 5, Keystone Health Plan East (KHP East) Out-of-Area Claims Dental Services .. Data that is Not Used .. Transaction Size.. Suffix on Highmark s NAIC Code for Vision Claims .. Ambulance Claims .. Provider and Service Facility Location Identification Claim Submission Acknowledgment .. National Provider Identifier (NPI) .. Balancing .. Real-Time Claim Adjudication and Estimation .. Real-Time 837 Submission Limitations.

4 General Requirements and Best Practices .. Data Detail for 837P .. 60GS Functional Group Header .. 61 REF Transmission Type Identification .. 62NM1 Submitter Name .. 62NM1 Receiver Name .. 63 PRV Billing/Pay-to Provider Specialty Information .. 63N3 Billing Provider Address .. 63N4 Billing Provider City/State/Zip .. 64 SBR Subscriber Information .. 64NM1 Subscriber Name .. 65NM1 Payer Name .. 65NM1 Patient Name .. 66 CLM Claim Information.. 66 DTP Date - Date Last Seen .. 67 DTP Date - Admission .. 67 PWK Claim Supplemental Information .. 67 AMT Total Purchase Service Amount .. 69 REF Mammography Certification Number .. 69CR2 Spinal Manipulation Information .. 69 CRC Patient Condition Information - Vision .. 70 PRV Referring Provider Specialty Information .. 70NM1 Rendering Provider Name .. 70 HighmarkTable of ContentsProvider EDI Reference Guide6 April 5, 2010 PRV Rendering Provider Specialty Information.

5 71NM1 Service Facility Location .. 71N3 Service Facility Location Address .. 72N4 Service Facility Location City/State/Zip.. 72 SBR Other Subscriber Information .. 73 AMT COB Patient Paid Amount.. 74NM1 Other Payer Name .. 75SV1 Service Line .. 76 AMT Sales Tax Amount .. 77PS1 Purchase Service Information.. 77 LIN Drug Identification .. 77 CTP Drug Pricing .. 78NM1 Rendering Provider Name .. 78 PRV Rendering Provider Specialty Information .. 78 REF Service Facility Location Secondary Identification .. 79 PRV Referring Provider Specialty Information .. 79 Chapter 9 Institutional Claim (837I) General Information and Guidelines for Submitting an 837I .. Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan .. KHP Central Out-of-Area Claims (Western Region).. Data that is Not Used .. Transaction Size.. Number of Lines per Claim.

6 Suffix on Highmark s NAIC Code .. Standalone Major Medical .. Provider Identification Numbers .. Claim Submission Acknowledgment .. National Provider Identifier (NPI) .. Balancing .. Real Time Claim Adjudication and Estimation .. Real-Time 837 Submission Limitations .. General Requirements and Best Practices .. Data Detail for 837I .. 90 HighmarkProvider EDI Reference GuideTable of ContentsApril 5, 20107GS Functional Group Header .. 90 REF Transmission Type Identification .. 92NM1 Submitter Name .. 92NM1 Receiver Name .. 93 PRV Billing/Pay-To Provider Specialty Information .. 93N3 Billing Provider Address.. 93N4 Billing Provider City/State/Zip .. 94 SBR Subscriber Information .. 94NM1 Subscriber Name .. 95NM1 Payer Name .. 95NM1 Patient Name .. 96 CLM Claim Information .. 96 DTP Discharge Hour .. 97 DTP Admission Date / Hour .. 97 PWK Claim Supplemental Information.

7 98CN1 Contract Information .. 99 REF Original Reference Number (ICN/DCN) .. 99K3 File Information .. 100HI Principal Procedure Information .. 101HI Other Procedure Information.. 102HI Value Information .. 102NM1 Attending Physician, Operating Physician, and Other Provider Name .. 103 PRV Attending Physician Specialty Information .. 104NM1 Service Facility Name .. 104N3 Service Facility Address .. 104N4 Service Facility City/State/Zip Code .. 105 SBR Other Subscriber Information .. 105NM1 Other Payer Name .. 106 LIN Drug Identification .. 106 CTP Drug Pricing .. 107NM1 Attending Physician, Operating Physician, and Other Provider Name .. 107 HighmarkTable of ContentsProvider EDI Reference Guide8 April 5, 2010 Chapter 10 Claim Acknowledgment (277) General Information and Guidelines for 277 Claim Acknowledg-ment.. Identifying the 837 in the 277 Claim Acknowledgment.

8 Front-End Editing: Level Types 1-5 .. Text Format Options.. Timeframe for Batch 277 Claim Acknowledgment .. Specifications .. Real-Time Claim Acknowledgment .. Claim Adjudication .. Claim Estimation.. General Requirements and Best Practices .. 113 Chapter 11 Claim Payment Advice (835) General Information and Guidelines for 835 .. Missing Checks .. Administrative Checks .. Availability of Payment Cycle 835 Transactions (Batch) . Highmark Private Business and Medicare Supplemental. Highmark Major Medical.. Highmark Oral Surgery.. Unavailable Claim Data .. Claim Overpayment Refunds .. Institutional Claims .. Professional Claims .. Electronic Funds Transfer (EFT) .. Capitation Payments .. Member Identification Numbers .. Data that is Not Used .. National Provider Identifier (NPI) .. Provider Payments from Member Health Care Real-Time 835 Response.

9 Real-Time Response for Claim Adjudication .. Real-Time 835 Response for Claim Estimation .. General Requirements and Best Practices .. Data Detail for 835 .. 128 HighmarkProvider EDI Reference GuideTable of ContentsApril 5, 20109GS Functional Group Header .. 129 BPR Financial Information .. 130 REF Receiver Identification .. 131 REF Additional Payer Identification .. 131N1 Payee Identification .. 132 REF Payee Additional Identification .. 132LX Header Number .. 133 CLP Claim Payment Information .. 133NM1 Service Provider Name .. 134 REF Other Claim Related Identification .. 134 SVC Service Payment Information .. 135 PLB Provider Adjustment .. 136 Chapter 12 Claim Status (276 & 277) General Instructions and Guidelines for 276 and 277.. General Instructions and Guidelines for 276 .. General Description .. Dental Services .. Data that Is Not Used.

10 Minimum Requirements .. Situational Elements and Data Content .. Requests Per Transaction Mode .. Patient with Coverage from an Out-of-State Blue Cross Blue Shield Plan .. General Instructions and Guidelines for 277 .. General Description of 277 .. Claim Splits.. Customer Service Requests .. Maximum Claim Responses per Subscriber/Patient/Depen-dent.. Corrected Subscriber and Dependent Level .. National Provider Identifier .. Data Detail for 276 .. 146GS Functional Group Header .. 146NM1 Payer Name .. 147NM1 Information Receiver Name .. 148 HighmarkTable of ContentsProvider EDI Reference Guide10 April 5, 2010NM1 Provider Name .. 148NM1 Subscriber Name .. 149 REF Payer Claim ID Number .. Data Detail for Claim Status Response (277) .. 150GS Functional Group Header .. 150NM1 Provider Name .. 151 REF Payer Claim Identification Number.