837i companion guide...aug 16, 2016 · version 1.2 – august 16, 2016 fmmis 837 institutional...

FMMIS 837 Institutional Health Care Claim and Institutional Encounter Claim Companion Guide

005010X223A2 Version 1.2

August 16, 2016

Florida Medicaid Management Information System Fiscal Agent Services Project

Disclaimer: The information contained in this Companion Guide is subject to change. EDI submitters are advised to check the EDI-Submission Information page on the “My Medicaid Florida” Web site (www.mymedicaid-florida.com) for the latest updates after go-live of version 5010.

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/66/Default.aspx

FMMIS 837 Institutional Health Care Claim and Institutional Encounter Claim Companion Guide Version 1.2 – August 16, 2016

ii HP Confidential © 2015 Hewlett-Packard Development Company, L.P.

The information contained herein is subject to change without notice.

Document Information Page

Required Information Definition Document: FMMIS 837 Institutional Health Care Claim and Institutional

Encounter Claim Companion Guide Document ID: Version: Version 1.19 QA Reviewer: QA Review Approval Date Location: Located in iTRACE Owner: Heather Lyons Author Heather Lyons <[email protected]> Approved by: Approval Date:

NOTE: The controlled master of this document is available online via iTRACE.

mailto:[email protected]


iii HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Amendment History Page Summary of Change

Version #

Modified Date

Modified By

Change/Update Details

1 12/24/10 Carl Bunche Creation of document – 1st Draft. 1.1 3/17/11 Carl Bunche The following change was made:

• Updated version number of transaction from “005010X223” to “005010X223A1”.

1.2 4/29/11 Carl Bunche The following change was made: • Updated version number of

transaction from “005010X223A1” to “005010X223A2”.

1.3 5/18/11 Carl Bunche The following changes were made: • Updated “Provider Identification” section (pg. 15).

Changed FL Medicaid’s “NPI Only” requirement date for 837 transactions from April 1 to May 1.

• Deleted RAS connection information (discontinued). 1.3 6/29/11 Reid O’Kelley Removed references to Remote Access Server (RAS). 1.3 7/7/11 Daniel Gray The following changes were made:

• Updated page number references to the 5010 Implementation Guide

• New/updated policy information regarding NPI in Section 6

1.4 12/20/2011 Daniel Gray The following changes were made: • Edited field descriptions for “ISA15” on page 5-2; • Replaced text in item 7 in “X12N 837 Business

Scenarios - Inbound Transactions” on page 6-1; • Edited text in item 13 in “X12N 837 Business

Scenarios - Inbound Transactions” on page 6-1; • Edited text in item 14 in “X12N 837 Business

Scenarios - Inbound Transactions” on page 6-1; • Added code/value and comment to “BHT06” on

page 7-1; • Removed references to 'SY' in “REF01” on page 7-2 as

this was specific to 4010X12; • Added comment to “REF02” on page 7-2; • Corrected page number for “PWK02” on page 7-6; • Edited code/value for “CAS02, CAS05, CAS08,

CAS11, CAS14, CAS17” on page 7-13; • Edited code/value for “CAS03, CAS06, CAS09,

CAS12, CAS15, CAS18” on page 7-14; • Added new Financial Class Code (FCC) table in

“Financial Class Codes Crosswalk” on page A-1.


4 HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Version

# Modified

Date

Modified By


1.5 2/14/2012 Daniel Gray The following changes were made: • Added '03' as an option for Encounter claims in ISA01

on page 5-1; • Added information for Encounter plan submission to

ISA02 on page 5-1; • Added Encounter Trading Partner submission

information to ISA06 on page 5-2; • Added clarification for Encounter Claim Billing

Provider Submission rules to loops 2000A and 2010AA on page 7-2;

• Added note regarding Attachments for Encounters on page 7-6;

• Added encounter specific information for CN1 segment (2300 loop) on page 7-7;

• Added clarification of requirements for Encounters and 2320 loop on pages 7-13 and 7-14;

• Added clarification of requirements for Encounter claims and 2330B loop on page 7-14; and

• Added rules for filing the 2430 loops on Encounter claims on page 7-16.

1.6 2/28/2012 Daniel Gray The following changes were made: • Corrected erroneous value in ST01 on page 5-4; • Removed unnecessary verbiage from CN101

description (2300 loop) on page 7-7; and • Clarified verbiage concerning MCO billing for

encounter claims in the 2320 and 2330B loops on pages 7-13 and 7-14.

1.7 8/8/2012 Daniel Gray The following change was made per AHCA request: • Replaced file size limit text to read: “Encounter files

have a file size limit of 5,000 claims per ISA/IEA.” on page 6-2.

1.8 3/15/2013 Daniel Gray The following changes were made:

• Added clarification on attachment requirements for “17. Medicare Part C Claims:” on page 6-4; and

• Added required values for SBR09 in the 2320 loop for Medicare Part C claims on 7-13.

1.9 6/13/2014 Daniel Gray The following changes were made:

• Added data for encounter resubmissions on pages 7-5 and 7-8.




Version

# Modified

Date

Modified By


1.10 12/1/2014 Heather Lyons The following changes were made:

• Added data for Hospice Billing FCC180 in “Financial Class Codes Crosswalk” on page A-1.

1/12/2015 Heather Lyons The following changes were made:

• Updated Appendix A “Financial Class Codes Crosswalk” on page A-1 to include additional values for Medicare Crossover Claims.


• Added data for MCO denied submissions for Encounter claims in the 2320 and 2430 loops on page on page 7-7, 7-13 and 7-16.

• Added data for MCO zero bill amount Encounter claims in “X12N 837 Business Scenarios - Inbound Transactions” on page 6-4.


• Updated document to include information for 999 Functional Acknowledgement.


• Updated wording in Loop 2300 REF segment for Encounter remediation.

1.14 8/10/2015 Heather Lyons The following changes were made: • Added clarification in wording in Loop 2300

REF segment for Encounter remediation • Updated FAQs to show allowed character length for

SFTP submissions. 1.15 9/9/2015 Heather Lyons The following changes were made:

• Added Frequency Code “3” for Hospice claims in the 2300 Loop CLM05-3 Segment.

1.16 2/19/2016 Molly Marotta The following changes were made:

• Updated information in Appendix A, Financial Class Codes Crosswalk

1.17 4/4/2016 Molly Marotta The following changes were made: • Appendix A • Page 6-3

1.18 7/5/2016 Molly Marotta The Following changes were made: • Appendix A




1.19 7/14/2016 Leah Cassorla The following changes were made: • Changed Zero Billed Language to reflect Zero Paid

language change in Tip Sheet 1.2 8/16/2016 Leah Cassorla The following Change was made:

• Corrected the NOTE on 7-7 for CN102 regarding the Amount Paid to provider.

• Corrected #18 on page 6-4 to read: CN101 must be '05' if CN102 (monetary amount) equals 0.




4010-5010 Change Log

This section specifies X12N 837 fields that have changed with the implementation of version 5010 (as it pertains to Florida Medicaid).

CG Page

Loop ID

Reference

Name

4010 Value

5010 Change

5-2 ISA11 Repetition Separator N/A Added: This field is now a repetition separator which is a delimiter and not a data element. This field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure. This value must be different than the data element separator, component element separator and the segment terminator. The 4010 name was Interchange Control Standards Identifier.

5-2 ISA12 Interchange Control Version Identifier

00401 Updated: Changed to “00501.”

5-4 GS08 Version/ Release/ Industry Identifier Code

004010X096A 2

Updated: Changed to “005010X223A2”

5-5 ST03 Implementation Convention Refer- ence

N/A Added: Must be identical to the value in GS08, which is 005010X223A2.

7-1 1000A PER Submitter EDI Con- tact Information

N/A Added: This is a new, required segment. This segment identifies the person in the submitter organization who deals with data transmission issues. If data transmission problems arise, this is the person to contact in the submitter organization.

7-2 7-9

2000A, 2310A

PRV02 Reference Identifi- cation Qualifier

ZZ Updated: Changed Taxon- omy Code qualifier from “ZZ” to “PXC.”


vii HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


CG

Page

Loop ID

Reference

Name

4010 Value

5010 Change

7-4 2010BB REF01 Reference Identifi- 1D Updated: Changed quali- 7-10 2310A cation Qualifier fier from “1D” (Medicaid 7-11 2310D Provider Number) to “G2” 7-12 2310E (Provider Commercial Num- 7-12 2310F ber).

NOTE: The “G2” qualifier can only be used by non- healthcare providers who cannot obtain an NPI.

7-4 2010BB N4 Payer City, State, Zip Code

N/A Updated: This field is now required in version 5010. All X12N submitters need to send the following information for this Payer Segment: City = Tallahassee State = Florida Zip Code = 32301

7-5 2300 CLM05-2 Facility Code Quali- fier

A Added: This is a new, required data element and code value. “A” (Uniform Billing Claim Form Bill Type) must be sent in every CLM segment for Institutional batches.

7-12 2310E REF01 Reference Identifi- cation Qualifier

1J Deleted: Value was removed from version 4010. The “1J” qualifier was the “Facility ID Number.” For 5010, submitters should send the code value of “LU” for “Location Number.”


viii HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


CG

Page

Loop ID

Reference

Name

4010 Value

5010 Change

7-14 2320 AMT Coordination of Benefits (COB) Payer Paid Amount

D Added: This is a new, situa- tional qualifier. Required when the claim has been adjudicated by another payer other than Medicaid (identified in Loop ID- 2330B).

7-14 2320 AMT Remaining Patient Liability

EAF Added: This is a new, situa- tional qualifier. In the judgment of the provider, this is the remaining amount to be paid after adjudication by the Other Payer identified in Loop ID-2330B of this iteration of Loop ID- 2320.

7-7 2300 CN1 CN102 – Monetary Amount

Added: Note: CLM02 contains the total monetary amount the health plan paid the provider.

7-16 2430 SVD SVD02 – Service Line Paid Amount

Changed language to reflect same in other 837 CGs: Enter the Third Party Payment Amount (TPL) OR amount Plan Paid to provider at the line item level only. ENCOUNTER - If CN101=05, SVD02 should be 0. If CN101=09, then SVD02 should be the detail other payer paid amount OR amount Plan Paid to provider.

7-7 2300 CN1 CN102 – Monetary Amount

Corrected: NOTE: CN102 contains the total monetary amount the health plan paid the provider.


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Table of Contents

1 Introduction .......................................................................................................................... 1-1 1.1 Purpose .................................................................................................................. 1-1 1.2 Implementation Timeline for the HIPAA 5010 standard .................................... 1-1

2 Transmission and Data Retrieval Methods 2-1

2.1 File/System Specifications.................................................................................... 2-1

3 Transmission Responses 3-1

4 EDI Support 4-1

5 Control Segment Definitions for Florida Medicaid 837 Transactions 5-1

5.1 ISA - Interchange Control Header Segment ........................................................ 5-1 5.2 IEA – Interchange Control Header....................................................................... 5-3 5.3 GS – Functional Group Header ............................................................................ 5-3 5.4 GE – Functional Group Trailer............................................................................. 5-4 5.5 ST – Transaction Set Header ................................................................................ 5-4 5.6 SE – Transaction Set Trailer ................................................................................ 5-5 5.7 Valid Delimiters .................................................................................................... 5-5

6 X12N 837 Business Scenarios - Inbound Transactions 6-1

7 X12N 837 Institutional Loop and Data Element Specific Information for Florida Medicaid ............................................................................................................ 7-1

8 Frequently Asked Questions 8-1

Appendix A Financial Class Codes Crosswalk .............................................................. A-1

Appendix B Occurrence Codes to Replacement Codes Crosswalk .............................. B-1

Appendix C Nursing Home Termination Codes to Patient Status Codes Crosswalk C-1

Appendix D Currently Used Revenue Codes to Equivalent Standard Codes Crosswalk .......................................................................................................................................... D-1


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1 Introduction

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health Services. The ANSI X12N implementation guides have been established as the standards of compliance for claim transactions.

The following information is intended to serve only as a companion guide to the HIPAA ANSI X12N implementation guides. The use of this guide is solely for the purpose of clarification. The information describes specific requirements to be used for processing data. This companion guide supplements, but does not contradict any requirements in the X12N implementation guide. Additional companion guides/trading partner agreements will be developed for use with other HIPAA standards, as they become available.

Additional information on the Final Rule for Standards for Electronic Transactions can be found at http://aspe.hhs.gov/admnsimp/final/txfin00.htm. The HIPAA Implementation Guides can be accessed at http://www.wpc-edi.com/hipaa/HIPAA_40.asp.

1.1 Purpose

This is the technical report document for the ANSI ASC X12N 837 Health Care Claims (837) transaction for Institutional claims. This document provides a definitive statement of what trading partners must be able to support in this version of the 837. This document is intended to be compliant with the data standards set out by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associated rules.

The 837 Institutional transaction is the electronic correspondent to the paper UB04 claim forms; therefore, any claim types submitted on the UB04 forms correlate to the 837 Institutional transaction, if data is submitted electronically.

All required segments within the 837 Institutional transactions must always be sent by the submitter and received by the payer. Optional information is sent when it is necessary for processing. Segments that are conditional are only sent when special criteria are met. Although required segments in the incoming transaction may not be used during claims processing, some of these data elements are returned in other transaction s such as the Unsolicited Claim Status (277U Transaction Set) and the Remittance Advice (835 Transaction Set).

1.2 Implementation Timeline for the HIPAA 5010 standard

Per Federal mandate, beginning on January 1, 2012, any electronic transaction files submitted by providers to a payer must be in the new HIPAA standard 5010 X12 format.

In the interest of providing a needed transition period between the current HIPAA 4010 standard and the incoming HIPAA 5010 standard, starting on July 11, 2011, Florida Medicaid accepts electronic medical transactions in both the current 4010 X12 and the new 5010 X12 format.

In line with the Federal mandate, this transition period ends on December 31, 2011, and all files submitted after that date must be in the new 5010 X12 standard format.

http://www.mymedicaid-florida.com/

http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Support/tabId/78/Default.aspx




2 Transmission and Data Retrieval Methods

HP supports several types of data transport depending upon the trading partner's need. Providers and their representatives can submit and receive data via the Web Portal and Value Added Networks (VANs)/Switch Vendors for interactive transactions.

1. Web Portal: Transaction files are uploaded/downloaded in the Trade Files menu on the secure Web Portal.

2. Value Added Networks (VANs) or Switch Vendors: VANs or Switch Vendors typically support interactive transactions through a dedicated connection to the fiscal agent. VANs sign a contract with the State and have unique, VAN specific communication arrangements with the fiscal agent. A list of approved vendors is listed on the fiscal agent Web site.

Detailed information to assist with EDI related processes are available on the Provider Public Web site at http://www.mymedicaid-florida.com.

Information available includes:

1. Trading Partner Testing Procedures (Ramp Manager) for all new trading partners, or trading partners adding a new transaction; and

2. Web Upload/Download instructions for submitters uploading/downloading via the secure Web Portal.

2.1 File/System Specifications

EDI only accepts Windows/PC/DOS formatted files. Any file transmitted to EDI must be named in accordance to standard file naming conventions, including a valid three character file extension.

EDI allows for the upload/download of zipped or compressed files. Any data file contained within the zipped file must contain a valid three character file extension. The recommended extension is .txt or .dat. Zipped files must not contain directory folders or structures and should contain only individual files.

Note: Only one X12 transaction file is permitted in each zipped file. Any data file that is 5MB or larger is required to be zipped or compressed before transmitting it to EDI.

The Web Portal is designed to support the following Internet browsers:

1. Internet Explorer, version 6 or later;

2. Firefox, version 1.5 or later; and

3. Opera, version 8.5 or later.

http://aspe.hhs.gov/admnsimp/final/txfin00.htm




3 Transmission Responses

For every transaction received, there is an expected response. The available responses are an Interchange Acknowledgement (TA1), the Functional Acknowledgement (997/999), and an Unsolicited Claim Status (277U).

Once a transaction is received, it goes through a 'front end' compliance check called a TA1. The TA1 is a means of replying to an interchange or transmission that has been sent. The TA1 verifies the envelopes only. The TA1 is a single segment and is unique in the sense that this single segment is transmitted without the GS/GE envelope structure. The TA1 segment provides the capability for the receiving trading partner to notify the sending trading partner of problems that were encountered in the interchange control structure.

Once the transaction has passed the 'front end' compliance check it then goes through a syntax compliance edit. This edit verifies the compliance within the ANSI X12 syntax according to the HIPAA Implementation Guides. The transaction receives a Functional Acknowledgement (997/ 999) to provide feedback on the transaction. The 997 functional acknowledgement contains accepted or rejected information. If the transaction contains any syntactical errors, the segments and elements in which the error occurred are reported in a rejected acknowledgement. If the transaction contained no syntactical errors, a positive 997 response is generated and the transaction is passed on for processing.

NOTE: The 997 will be replaced with the 999 effective December 11, 2015.




4 EDI Support

The HP EDI Operations Team is available to support trading partners and providers that exchange transactions electronically. Support functions include:

1. Enrollment processing for trading partners requesting to submit transactions electronically;

2. Installation assistance and submission support for Provider Electronic Solutions (PES) software;

3. Provide assistance to billing agents, clearinghouses and software vendors;

4. Identifying and troubleshooting technical issues; and

5. Data Exchange help.

The providers may reach EDI staff Monday through Friday 8:00 a.m. to 5:00 p.m. EST (Eastern Standard Time) at the EDI Helpdesk, (866) 586-0961.




5 Control Segment Definitions for Florida Medicaid 837 Transactions

Note the page numbers listed below in each of the tables represent the corresponding page number in the X12N 837 HIPAA Implementation Guide [837_5010_x223].

X12N EDI Control Segments ISA - Interchange Control Header Segment IEA - Interchange Control Trailer Segment GS - Functional Group Header Segment GE - Functional Group Trailer Segment ST - Transaction Set Header SE - Transaction Set Trailer TA1 - Interchange Acknowledgement

5.1 ISA - Interchange Control Header Segment

Communications transport protocol interchange control header segment. This segment within the X12N implementation guide identifies the start of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file header record.

837 Institutional Health Care Claim

Page Loop ID Reference Name Code/Value Notes/Comments C.3 N/A ISA Interchange

Control Header Segment

C.4 N/A ISA01 Authorization Information Qualifier

00, 03 '00' – No Authorization Information Present ENCOUNTER - '03' - Additional Data Identification

C.4 N/A ISA02 Authorization Information

[space fill] ENCOUNTER - MCO Medicaid ID + [space fill]

C.4 N/A ISA03 Security Information Qualifier

00 '00' – No Security Information Present

C.4 N/A ISA04 Security Information

[space fill]

C.4 N/A ISA05 Interchange ID Qualifier

ZZ 'ZZ' – Mutually Defined





Page Loop ID Reference Name Code/Value Notes/Comments C.4 N/A ISA06 Interchange Sender

ID ‘Trading Partner ID’

supplied by Florida Medicaid, left justified space filled. ENCOUNTER - Encounter Specific Trading Partner ID, left justified, space filled.

C.5 N/A ISA07 Interchange ID Qualifier

ZZ 'ZZ' – Mutually Defined

C.5 N/A ISA08 Interchange Receiver ID

77027 ‘77027’ left justified and space filled. Florida Medicaid Sender ID.

C.5 N/A ISA09 Interchange Date The date format is YYMMDD.

C.5 N/A ISA10 Interchange Time The time format is HHMM. C.5 N/A ISA11 Repetition

Separator ^ ‘^’

C.5 N/A ISA12 Interchange Control Version Number

00501 ‘00501’ – Control Version Number

C.5 N/A ISA13 Interchange Control Number

Interchange Unique Control Number – Must be identical to IEA02

C.6 N/A ISA14 Acknowledgement Requested

1, 0 ‘1’ – Acknowledgement Requested ‘0’ – No Acknowledgement Requested

C.6 N/A ISA15 Usage Indicator P ‘P’ – Production Data

C.6 N/A ISA16 Component Element Separator

: ‘:’ – Component Element Separator




5.2 IEA – Interchange Control Header

Communications transport protocol interchange control trailer segment. This segment within the X12N implementation guide defines the end of an interchange of zero or more functional groups and interchange-related control segments. This segment may be thought of traditionally as the file trailer record.

837 Institutional Health Care Claims

Page Loop ID Reference Name Code/Value Notes/Comments C.10 N/A IEA Interchange

Control Trailer

C.10 N/A IEA01 Number of Included Functional Groups

Number of included Functional Groups

C.10 N/A IEA02 Interchange Control Number.

Must be identical to the value in ISA13

5.3 GS – Functional Group Header

Communications transport protocol functional group header segment. This segment within the X12N implementation guide indicates the beginning of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch header record.


Page Loop ID Reference Name Code/Value Notes/Comments C.7 N/A GS Functional Group

Header

C.7 N/A GS01 Functional ID Code HC 'HC' – Health Care Claim (837)

C.7 N/A GS02 Application Sender’s Code

‘Trading Partner ID’ supplied by Florida Medicaid, left justified space filled.

C.7 N/A GS03 Application Receiver’s Code

77027 ‘77027’ left justified and space filled. Florida Medicaid Sender ID.

C.7 N/A GS04 Date The date format is CCYYMMDD.

C.8 N/A GS05 Time The time format is HHMM. C.8 N/A GS06 Group Control

Number Group Control Number –

Must be identical to GE02.





Page Loop ID Reference Name Code/Value Notes/Comments C.8 N/A GS07 Responsible

Agency Code X ‘X’ – Responsible Agency

Code C.8 N/A GS08 Version/ Release/

Industry Identifier Code

005010X223 A2

Version/ Release/ Industry Identifier Code

5.4 GE – Functional Group Trailer

Communications transport protocol functional group trailer segment. This segment within the X12N implementation guide indicates the end of a functional group and provides control information concerning the batch of transactions. This segment may be thought of traditionally as the batch trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments C.9 N/A GE Functional Group

Trailer

C.9 N/A GE01 Number of Transaction Sets Included

Number of included Transaction Sets

C.9 N/A GE02 Group Control Number

Must be identical to the value in GS06.

5.5 ST – Transaction Set Header

Communications transport protocol transaction set header segment. This segment within the X12N implementation guide indicates the start of the transaction set and assigns a control number to the transaction. This segment may be thought of traditionally as the claim header record.


Page Loop ID Reference Name Code/Value Notes/Comments 67 N/A ST Transaction Set

Header

67 N/A ST01 Transaction Set Identifier Code

'837' '837' - Health Care Claim

67 N/A ST02 Transaction Set Control Number

Transaction Control Number





Page Loop ID Reference Name Code/Value Notes/Comments Increment by 1 when

multiple transaction sets are submitted. Must be identical to SE02.

67 N/A ST03 Implementation Convention Reference

Must be identical to the value in GS08.

5.6 SE – Transaction Set Trailer

Communications transport protocol transaction set trailer. This segment within the X12N implementation guide indicates the end of the transaction set and provides the count of transmitted segments [including the beginning (ST) and ending (SE) segments]. This segment may be thought of traditionally as the claim trailer record.


Page Loop ID Reference Name Code/Value Notes/Comments 488 N/A SE Transaction Set

Trailer

488 N/A SE01 Number of Included Segments

Total number of segments included in Transaction Set including ST and SE

488 N/A SE02 Transaction Set Control Number

Must be identical to the value in ST02

5.7 Valid Delimiters The delimiters documented below are used for Florida Medicaid, unless otherwise requested by a trading partner.

Definition ASCII Decimal Hexadecimal Segment Separator ~ 126 7E Element Separator * 42 2A Compound Element Separator : 58 3A Repetition Separator ^ 94 5E




6 X12N 837 Business Scenarios - Inbound Transactions

This section contains Payer-specific business rules and limitations for the 837 Institutional transactions.

1. Subscriber, Insured = Recipient in the Florida Medicaid Eligibility Verification System:

The Florida Medicaid Eligibility Verification System does not allow for dependents to be enrolled under a primary subscriber, rather all enrollees/members are primary subscribers within each program or Managed Care Organization.

2. Provider Identification = NPI or Medicaid ID (Providers without an NPI only):

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandated the implementation of a National Provider Identifier (NPI). Most health care providers must register with the National Plan and Provider Enumeration System and receive a unique NPI. The intent of the HIPAA regulations was to require all health plans to convert their claims processing systems to use only the NPI for claims processing and reporting for providers required to obtain an NPI. Because of the complexities of this conversion by health care plans and providers, the use of the NPI has not yet been strictly enforced. However, Medicaid claims submitted on and after January 1, 2011, have new requirements for the use of the NPI.

Beginning on January 1, 2011, the NPI is required on all electronic transactions and paper claims from providers who qualify for an NPI. Florida Medicaid still accepts transactions containing the Provider's Medicaid ID, but any qualifying claims that lack the NPI are denied.

Starting on May 1, 2011, Florida Medicaid no longer accepts electronic claim transactions (837D, 837I, and 837P) containing the Florida Medicaid ID submitted by providers who qualify for an NPI. Any electronic claims sent by qualifying providers on or after May 1, 2011 that contain the provider's Florida Medicaid Provider ID are denied, even if they also contain the NPI.

Please note that paper claims are not affected by this change.

For all non- healthcare providers where an NPI is not assigned, the claim must contain the Florida Medicaid Provider Number with the appropriate loops within the REF segment where REF01 equals G2.

3. Logical File Structure:

There can be only one interchange (ISE/IEA) per logical file. The interchange can contain multiple functional groups (GS/GE) however; the functional groups must be the same type.

4. Submitter:

Submissions by non-approved trading partners are rejected.

5. Claims:

Claims must be submitted in separate ISA/IEA envelopes.

6. Response/997 Functional Acknowledgement:




A response transaction is returned to the trading partner that is present within the ISA06 data element.

The Agency for Health Care Administration (AHCA) provides a 997 Functional Acknowledgment for all transactions that are received.

You will receive this acknowledgment within 48 hours unless there are unforeseen technical difficulties. If the transaction submitted was translated without errors for a request type transaction, i.e., 270 or 276, you will receive the appropriate response transaction generated from the request. If the transaction submitted was a claim transaction, i.e., 837, you will receive either the 835 or the unsolicited 277.

NOTE: The 835 and unsolicited are only provided weekly. NOTE: The 997 will be replaced with the 999 effective December 11, 2015.

7. When REF01 = EI:

If REF01 equals EI (EIN) within any loop, the value in the corresponding REF02 segment must be totally numeric. The dash traditionally included with this number should be omitted.

NOTE: Neither number should contain dashes or hyphens, as this causes the data element to exceed the maximum allowed number of characters.

8. Claims Allowed per Transactions (ST/SE envelope):

The HIPAA implementation guide states on the CLM (Claim Information) segment that the developers recommend that trading partners limit the size of the transaction (ST/SE) envelope to a maximum of 5,000 CLM segments.

Encounter files have a file size limit of 5,000 claims per ISA/IEA.

9. Document Level:

AHCA processes files at the claim level. It is possible based on where the error(s) occur within the hierarchical structure that some claims may pass compliance and others will fail compliance. Those claims that pass compliance are processed within the Florida Medicaid Management Information System (FMMIS). Those claims that fail compliance are reported on the 997. NOTE: The 997 will be replaced with the 999 effective December 11, 2015.

10. Dependent Loop:

For AHCA, the subscriber is always the same as the patient (dependent). Claims containing data in the Patient Hierarchical Level (2000C loop) will not process correctly.

11. Compliance Checking:

Inbound 837 transactions are validated through Strategic National Implementation Process (SNIP) Level 4. In addition to Level 4, Level 7 patient (dependent) level occurs if 2000C patient loop is received. All other levels are validated within the FMMIS.

12. Identification of TPL:

For each claim at the header level, if loop 2320 (Other Subscriber Information) is present and SBR09




(Claim Filing Indicator) is not equal to MB (Medicare), 16 (HMO Medicare Risk), HM (HMO) or MC (Medicaid), the COB Payer Paid Amounts (AMT01=D) received in the 2320 loop(s) are summed together for the Payer Paid Amount.

NOTE: The 2320 loop can repeat multiple times per claim.

13. Processing for the 2300-HI Segment for the "Principal Procedure Information":

AHCA only uses the value sent in the HI01-2, where HI01-1 equals BR in the Principal Procedure Information HI segment. If the value of BBR or CAH is sent within the HI01-1, the value received in the HI01 -2 is not used for processing the claim.

NOTE: HIPAA allows the BBR, CAH and/or BR qualifier values at the claim level within the HIxx-1 composite element, the HCPCS procedure code value would then be placed in the HIxx-2 composite element. For institutional claims, AHCA only allows the HCPCS procedure code at the detail level within the 2400-SV202-2, where 2400-SV202-1 = "HC". If the HCPCS procedure code is received within the HI segment, the claim will not fail compliance. However, the claim will not process correctly within the adjudication system.

14. Processing for the 2300-HI Segment for the "Other Procedure Information":

AHCA only uses the value sent in the HI01-2, where HI01-1 equals BQ in the Principal Procedure Information HI segment.

HIPAA allows the BQ or BBQ qualifier values at the claim level within the HIxx-1 composite element, the HCPCS procedure code value would then be placed in the HIxx-2 composite element. For institutional claims, AHCA only allows the HCPCS procedure code at the detail level within the 2400-SV202-2, where 2400-SV202-1 = "HC." If the HCPCS procedure code is received within the HI segment, the claim will not fail compliance. However, the claim will not process correctly within the adjudication system. NOTE: BR and BQ qualifiers are for ICD-9 claims only. Effective 10/01/2015, ICD-10 qualifier codes should be used. Use BR and BQ for claims prior to a DOS of 10/01/2015. Use BBR and BBQ after or on DOS 10/01/2015.

15. National Drug Code (NDC):

The NDC number is used for reporting prescribed drugs and biologics when required by government regulation, or as deemed by the provider to enhance claim reporting/adjudication processes. In order for AHCA to fully realize the drug rebate savings for claims billed, an NDC Code for the billed drug is required effective January 1, 2007.

16. Hard Copy Attachments:

The PWK segment is used to indicate that supporting documentation, or "attachments" for the claim will be submitted. An ACN (attachment control number) is used to link the attachment to claims and is defined in PWK06 (Identification Code). It is not recommended to use the same ACN more than one time. Additionally, the ACN must not contain PHI. For the element summary, please see "Hard Copy Attachments" in section 5. Hard Copy Attachments for claims submitted on the 837 may be submitted via fax. All attachments must be submitted with a fax cover page. This cover page may be obtained on the secure Web Portal after submitting the 837 and should be the first page of the fax transmission. If you are unable to obtain the cover page from the secure Web Portal, a proprietary cover page may be sent,




however this slows the process of matching a claim to its accompanied attachment and is not recommended. The cover page must include the following three items: Medicaid billing provider number on the claim, Recipient ID, and the ACN from PWK06. The fax number for Hard Copy Attachments is 866-267-3775.

It is imperative that the fax submission only include documents associated with a single claim; if multiple attachments are sent in a single fax transmission, all documents received are assigned to the claim containing the ACN that appears on the fax cover sheet, and all other claims continue to show that attachments have not been received.

17. Medicare Part C Claims:

Medicare Part C (Medicare Advantage) claims should be submitted with the required documents attached (both an EOMB and a Medicare Part C crossover form). Such claims that are submitted without attachments will be processed by Florida Medicaid, but will be denied payment.

Any Medicare Part C claims received electronically via the Web Portal or batch submission that have been flagged as containing an attachment will temporarily suspend pending receipt of the noted attachment by Florida Medicaid. By default, if the attachment is not received within 21 days, the original claim will be denied payment.

18. MCO Encounters with Zero Plan Paid Amount :

CN101 must be '05' if CN102 (monetary amount) equals 0.




7 X12N 837 Institutional Loop and Data Element Specific Information for Florida Medicaid

This section specifies X12N 837 fields for which Florida Medicaid has specific requirements.


Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

68 N/A BHT Beginning Segment 68 N/A BHT02 Transaction Set

Purpose Code 00 ‘00’ – Original

69 N/A BHT06 Transaction Type Code

CH, RP 'CH' - Chargeable (Use with Institutional Health Care Claim) 'ENCOUNTER - 'RP' - Reporting

71 1000A NM1 Submitter Name 72 1000A NM108 Identification Code

Qualifier 46 ‘46’ – Electronic Transmitter

Identification Number (ETIN) 72 1000A NM109 Identification Code ‘Trading Partner ID’ supplied by

FL Medicaid 73 1000A PER Submitter EDI

Contact Information

74 1000A PER01 Contact Function Code

IC ‘IC’ – Information Contact

74 1000A PER02 Name Required if different than the name contained in the Submitter Name (Loop 1000A, NM1 segment)

74 1000A PER03 Communication Number Qualifier

EM, FX, TE

EM – Electronic Mail FX – Fax TE - Telephone

74 1000A PER04 Communication Number

Email Address, Fax Number or Telephone Number (including the area code)

76 1000B NM1 Receiver Name

77 1000B NM103 Name Last or Organization Name

‘STATE OF FLORIDA MEDICAID’

77 1000B NM109 Identification Code ‘77027’ – Florida Medicaid Payer ID





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

80 2000A PRV Billing Provider Specialty Information

ENCOUNTER - When required for NPI crosswalk, this loop should contain the Taxonomy Code for the MCO Paid Provider (see 2010AA below).

80 2000A PRV01 Provider Code BI ‘BI’ – Billing

80 2000A PRV02 Reference Identification Qualifier

PXC ‘PXC’ – Health Care Provider Taxonomy Code

80 2000A PRV03 Reference Identification

Provider Taxonomy Code

84 2010AA NM1 Billing Provider Name

ENCOUNTER - This loop should contain the NPI information for the Provider paid by the MCO. This information was previously sent in the 2010AB loop of the 4010X12 transaction set. NOTE: For MCO Plan ID submission information, see ISA01 and ISA02.

85 2010AA NM101 Entity Identifier Code 85 ‘85’ – Billing Provider 86 2010AA NM108 Identification Code

Qualifier XX ‘XX’ – Centers for Medicare and

Medicaid Services National Provider Identifier (NPI)

86 2010AA NM109 Identification Code HIPAA National Provider Identifier

87 2010AA N4 Billing Provider City, State, Zip Code

89 2010AA N403 Postal Code Billing Provider 9-digit Zip Code 90 2010AA REF Billing Provider Tax

Identification

90 2010AA REF01 Reference Identification Qualifier

EI EI – Employer ID (EIN)

90 2010AA REF02 Reference Identification

Valid 9-digit Employer ID number





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

Subscriber Level NOTE: For Florida Medicaid, the insured and the patient are always the same person. Use this HL segment to identify the recipient and proceed to Loop 2300. Do not send the Patient Hierarchical Level (Loop 2000C). Claims received with the 2000C Loop may not process correctly. 107 2000B HL Subscriber

Hierarchical Level

108 2000B HL03 Hierarchical Child Code

22 “22” – Subscriber

108 2000B HL04 Hierarchical Child Code

0 “0” – No Subordinate HL Segment in this Hierarchical Structure

109 2000B SBR Subscriber Information

109 2000B SBR01 Payer Responsibility Sequence Number Code

The X12N 837I does not support the use of the Financial Class Code that is currently billed on Hospital claims. Claim Filing Indicators and the Payer Responsibility Sequence, which indicates the relationship each payer has to Medicaid and other payers on each claim replaces the data supplied by the Financial Class Code. See Appendix A for a crosswalk of Financial Class Codes to the Claim Filing Indicator/Payer Responsibility Sequence.

109 2000B SBR Subscriber Information

110 2000B SBR09 Claim Filing Indicator Code

See Comment on 2000B-SBR01.

112 2010BA NM1 Subscriber Name 113 2010BA NM102 Entity Type Qualifier 1 “1” - Person 113 2010BA NM108 Identification Code

Qualifier MI “MI” – Member Identification

Number





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

114 2010BA NM109 Identification Code Florida Recipient 10-digit Medicaid ID

116 2010BA N4 Subscriber City, State, Zip Code

116 2010BA N401 City Name Subscriber City 116 2010BA N402 State or Province

Code Subscriber State

117 2010BA N403 Postal Code Subscriber Zip Code 122 2010BB NM1 Payer Name 123 2010BB NM103 Name Last or

Organization Name “STATE OF FLORIDA

MEDICAID” 123 2010BB NM108 Identification Code

Qualifier PI “PI” – Payer Identification

123 2010BB NM109 Identification Code 77027 “77027” – Florida Medicaid Payer ID

125 2010BB N4 Payer City, State, Zip Code

125 2010BB N401 City Name Tallahassee 125 2010BB N402 State or Province

Code FL

126 2010BB N403 Postal Code 32301 129 2010BB REF Billing Provider

Secondary Identification

129 2010BB REF01 Reference Identification Qualifier

G2 “G2” – Provider Commercial Code NOTE: This qualifier may only be used by non-healthcare providers who do not possess a NPI ID (i.e., Med waivers)

130 2010BB REF02 Reference Identification

Florida Medicaid Provider ID

143 2300 CLM Claim Information 144 2300 CLM01 Claim Submitter’s

Identifier Patient Control Number

NOTE: Value received is returned on the 835 Remittance Advice.





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

145 2300 CLM05-1 Facility Type Code Value received is the 1st two positions of the Type of Bill (TOB).

145 2300 CLM05-2 Facility Code Qualifier

A “A” – Uniform Billing Claim Form Bill Type

145 2300 CLM05-3 Claim Frequency Type Code

Value received is the 3rd position of the Type of Bill (TOB). Frequency Code also indicates whether the current claim is an original claim, a void, or an adjustment. Valid values are as follows: “1” = Original Claim “3” = Hospice Only “7” = Adjustment (Replacement of Paid Claim) “8” = Void (Credit only). The ICN to credit should be placed in the REF02 where REF01=”F8”. Providers must use the most recently paid ICN when voiding or adjusting. Consult your appropriate Reimbursement Handbook for additional guidelines for filing voids and adjustments. ENCOUNTER: Use '1' as a frequency code when resubmitting a denied claim.

149 2300 DTP Discharge Hour 149 2300 DTP01 Date/Time Qualifier 096 “096” – Discharge 149 2300 DTP02 Date Time Period

Format Qualifier TM “TM” – Time (HHMM)





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

149 2300 DTP03 Date Time Period Discharge Hour Bill the Discharge Hour on all claims involving final services rendered. When a Discharge Hour is submitted, the Discharge Date is populated with the Statement Last Date of Service. This field only applies for nursing home patients discharged prior to the end of the month.

150 2300 DTP Statement Dates 150 2300 DTP01 Date/Time Qualifier 434 “434” – Statement 150 2300 DTP02 Date Time Period

Format Qualifier RD8 “RD8” - Range of Dates

Expressed in Format CCYYMMDD-CCYYMMDD

153 2300 CL1 Institutional Claim Code

153 2300 CL103 Patient Status Code The X12N 837I does not support the use of the Nursing Home Termination Codes currently billed on Nursing Home claims. The Termination Code is derived from the Patient Status Code. See Section 7 - Program Specific Required Information for Florida Medicaid Claims Processing.

Hard Copy Attachments 154 2300 PWK Claim Supplemental

Information ENCOUNTER - Attachments are

not permitted for Encounter Claims.

155 2300 PWK01 Report Type Code EB “EB” – Report Transmission Code (Coordination of Benefits or Medicare Secondary Payer)

155 2300 PWK02 Report Transmission Code

FX “FX” – By Fax

157 2300 PWK05 Identification Code Qualifier

AC “AC” – Attachment Control Number

157 2300 PWK06 Identification Code The Attachment Control number assigned to the attachment created by the submitter.





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

158 2300 CN1 Contract Information ENCOUNTER - This information is required on all encounter claims. This refers to the contract between the plan and the provider paid by the plan.

158 2300 CN101 Contract Type Code 02, 05, 09

The X12N 837I does not support the use of the Level of Care as it is currently billed on Nursing Home claims. Enter Contract Type “02” (Per Diem) in the Contract Type Code field and the Florida Level of Care value in the Reference Identification field. See “Hard Copy Attachments” section (page 17) or the Florida Medicaid Provider Reimbursement Handbook for the valid values for the Level of Care. ENCOUNTER - Required - Use '09' for FFS Use '05' for Capitation Refer to Implementation Guide for a list of valid values.

158 2300 CN102 Contract Amount Nursing Home per diem amount (Contract Amount) ENCOUNTER - If CN101= 05, then Capitated Rate If CN101= 09, then Other Payer Amount Paid (the sum of SVD02 elements in the 2430 loop) NOTE: CN102 contains the total monetary amount the health plan paid the provider.

159 2300 CN104 Contract Code Level of Care value (Contract Code)

163 2300 REF Referral Number




163 2300 REF01 Reference Identification Qualifier

9F “9F” – Referral Number





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

163 2300 REF02 Reference Identification

Enter MediPass Referral Number if “9F” value is used.

164 2300 REF Prior Authorization 164 2300 REF01 Reference

Identification Qualifier

G1 “G1” – Prior Authorization


Enter the 10-digit Prior Authorization Number. Enter this number only if the services rendered required and received Prior Authorization from AHCA or a Peer Review Organization such as KePRO or First Mental Health. This number must be entered with the qualifier “G1” (Prior Authorization Number).

166 2300 REF Payer Claim Control Number


F8 “F8” – Original Reference Number NOTE: The F8 qualifier should only be used when voiding or adjusting a previously paid encounter. This qualifier should not be used for resubmission of denied encounters


Enter the 13-digit ICN or 17-digit TCN assigned to the original claim submission. (ICN/TCN to be credit/voided).

170 2300 REF Claim Identifier for Transmission Intermediaries

ENCOUNTER - This segment is to be used when resubmitting previously denied encounter claims for remediation. NOTE: Denied encounters cannot be voided or adjusted





D9 'D9' - Claim Number ENCOUNTER - This will be sent when a previously denied claim is being resubmitted. Resubmission of previously denied claims must occur within 30 days of the original denial. NOTE: The D9 qualifier should only be used when resubmitting a denied encounter. This qualifier should not be used for adjustments or voids


The ICN of the most recent denied Encounter claim.

176 2300 K3 File Information





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

177 2300 K301 Fixed Format Information

MCO Receipt Date – Format CCYYMMDD.

271 2300 HI Occurrence Information

For those HI Segments Page 184 through Page 304 within the 837I Implementation Guide that can repeat multiple times and allow up to 12 occurrences of information within each segment are captured and stored within the MMIS.

271- 282

2300 HI01-1 - HI12-1

Code List Qualifier Code

BH “BH” – Occurrence See Section 7 for a list of current Florida-specific Occurrence Codes to replacement codes and their description.

Attending Provider NOTE: Required for Inpatient Services 319 2310A NM1 Attending Provider

Name

319 2310A NM101 Entity Identifier Code 71 “71” – Attending Provider 321 2310A NM108 Identification Code

Qualifier XX “XX” – Centers for Medicare and


321 2310A NM109 Identification Code 322 2310A PRV Attending Provider

Specialty Information

322 2310A PRV01 Provider Code AT “AT” – Attending 322 2310A PRV02 Reference

Identification Qualifier

PXC “PXC” – Health Care Provider Taxonomy Code

322 2310A PRV03 Reference Identification

Rendering Provider Taxonomy Code. Used for claims submitted with NPI.

324 2310A REF Attending Provider Secondary Identification





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

324 2310A REF01 Reference Identification Qualifier

0B, G2 “0B” – State License Number “G2” – Provider Commercial Number Enter the Florida Department of Professional Regulation (DPR) medical license number for the attending physician (the physician primarily responsible for the care of the patient) or the medical license number of the resident physician. Enter the license information in the following format: ME9999999. This number must be entered with the qualifier „0B‟ (State License Number). NOTE: This is not required for nursing homes. NOTE: The “G2” qualifier should only be used for non- healthcare providers.

Rendering Provider NOTE: Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. 336 2310D NM1 Rendering Provider

Name

337 2310D NM101 Entity Identifier Code 82 “82” – Rendering Provider 338 2310D NM108 Identification Code



338 2310D NM109 Identification Code 339 2310D REF Rendering Provider






Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

339 2310D REF01 Reference Identification Qualifier

0B, G2 “0B” – State License Number “G2” – Provider Commercial Number Enter the Florida Department of Professional Regulation (DPR) medical license number for the attending physician (the physician primarily responsible for the care of the patient) or the medical license number of the resident physician. Enter the license information in the following format: ME9999999. This number must be entered with the qualifier “0B‟ (State License Number). NOTE: This is not required for nursing homes. NOTE: The “G2” qualifier should only be used for non- healthcare providers.

Service Facility NOTE: Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). 341 2310E NM1 Service Facility Name 342 2310E NM101 Entity Identifier Code 77 “77” – Service Location 342 2310E NM108 Identification Code



342 2310E NM109 Identification Code 344 2310E N3 Service Facility

Location Address

344 2310E N301 Address Information Service Facility Location Address Line

347 2310E REF Service Facility Name Secondary Identification





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

347 2310E REF01 Reference Identification Qualifier

LU, G2 “LU” – Location Number “G2” – Provider Commercial Number NOTE: The “G2” qualifier should only be used for non- healthcare providers.

Referring Provider NOTE: Required on an outpatient claim when the Referring Provider is different than the Attending Provider. 349 2310F NM1 Referring Provider

Name

350 2310F NM101 Entity Identifier Code DN “DN” – Referring Provider 351 2310F NM108 Identification Code



351 2310F NM109 Identification Code 352 2310F REF Referring Provider


352 2310F REF01 Reference Identification Qualifier

0B, G2 “0B” – State License Number “G2” – Provider Commercial Number Enter the Florida Department of Professional Regulation (DPR) medical license number for the attending physician (the physician primarily responsible for the care of the patient) or the medical license number of the resident physician. Enter the license information in the following format: ME9999999. This number must be entered with the qualifier “0B‟ (State License Number). NOTE: This is not required for nursing homes. NOTE: The “G2” qualifier should only be used for non- healthcare providers.





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

Other Subscriber Information ENCOUNTER -Loop 2320 (Other Subscriber Information) is required on all encounter claims NOTE: For encounter claims, the MCO should always be reported as one of the other payers. For example, when there is TPL, the TPL is primary and the MCO is secondary. When there is no TPL, the MCO is primary. 354 2320 SBR Other Subscriber

Information

355 2320 SBR01 Payer Responsibility Sequence Number Code

Enter the appropriate standard code. The X12N 837I does not support the use of the Financial Class Code that is currently billed on Hospital claims. Claim Filing Indicators and the Payer Responsibility Sequence, which indicates the relationship each payer has to Medicaid and other payers on each claim replaces the data supplied by the Financial Class Code. See Appendix A for a crosswalk of Financial Class Codes to the Claim Filing Indicator/Payer Responsibility Sequence.

356 2320 SBR09 Claim Filing Indicator Code

See Comment on 2320-SBR01.

358 2320 CAS Case Level Adjustments

'16' '16' - HMO Medicare Risk (required for Medicare Part C claims). See Comment on 2320-SBR01 for Financial Class Code classification.

360- 2320 CAS02, Adjustment Reason ‘1’, ‘2’, For Inpatient: 363 CAS05, Code ‘A1’ ‘1’ - Deductible

CAS08, ‘2’ - Coinsurance CAS11, Other external code source values CAS14, from code source 139 are CAS17 allowed.

ENCOUNTER: ‘A1’ - MCO Denied Claim





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

360- 2320 CAS03, Adjustment Amount If Adjustment Group Code 363 CAS06, (CAS01)=PR and Adjustment

CAS09, Reason Code value is: CAS12, “1” enter the Medicare CAS15, Deductible Amount. CAS18 “2” enter the Medicare

Coinsurance Amount. 364 2320 AMT Coordination of

Benefits (COB) Payer Paid Amount

364 2320 AMT01 Amount Qualifier Code

D “D” – Payer Amount Paid

364 2320 AMT02 Identification Code Qualifier

Other Payer Amount Paid (TPL or MCO)

365 2320 AMT Remaining Patient Liability

365 2320 AMT01 Amount Qualifier Code

EAF “EAF” – Amount Owed

365 2320 AMT02 Identification Code Qualifier

Other Payer Amount Paid (TPL or MCO)

Other Payer ENCOUNTER -Loop 2330B (Other Payer Name) is required on all encounter claims NOTE: For encounter claims, the MCO should always be reported as one of the other payers. For example, when there is TPL, the TPL is primary and the MCO is secondary. When there is no TPL, the MCO is primary. 384 2330B NM1 Other Payer Name 385 2330B NM108 Identification Code

Qualifier PI, XV “PI” – Payor Identification

“XV” – Centers for Medicare and Medicaid Services Plan ID

385 2330B NM109 Identification Code This number must be identical to at least once occurrence of the 2430-SVD01 to identify the other payer. Florida Medicaid captures third party payment amount(s) from the service line(s) in 2430-SVD02 for Outpatient Claims. NOTE: The 2320/2330 Loop(s)





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

389 2330B DTP Claim Check or Remittance Date

389 2330B DTP01 Date/Time Qualifier 573 “573” – Date Claim Paid 389 2330B DTP02 Date Time Period

Format Qualifier D8 “D8” – Date Expressed in Format

CCYYMMDD 389 2330B DTP03 Date Time Period

Service Line Number 423 2400 LX Service Line Number 423 2400 LX01 Assigned Number Florida Medicaid accepts up to

the HIPAA allowed 999 detail lines per claim.

Institutional Service Line 424 2400 SV2 Institutional Service

Line

424 2400 SV201 Service Line Revenue Code

Nursing home submitters must enter a revenue code. Enter Revenue Code “0101” and the per diem amount if no home days or hospital days need to be reported. Enter Revenue Code “0185” for days spent in hospital or Service Line Revenue Code „0182‟ for days spent at home. (Nursing Home only)

425 2400 SV202-1 Product/Service ID Qualifier

HC “HC” – Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes

428 2400 SV205 Quantity Enter the number of days spent in hospital or at home. Florida Medicaid processes only the whole number when units are entered with decimals. Example: Units entered on the transaction 3.75 are processed as 3 units.

Drug Identification 449 2410 LIN Drug Identification 451 2410 LIN02 Service ID Qualifier N4 “N4” – National Drug Code





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

451 2410 LIN03 Drug Identification Enter National Drug Code in 5-4- 2 Format

452 2410 CTP Drug Quantity 452 2410 CTP04 Quantity National Drug Unit Count 453 2410 CTP05-1 Unit or Basis for

Measurement Code UN “UN” - Unit

Line Adjudication Information ENCOUNTER -Loop 2430 (name loop) Required on all encounter claims NOTE: Other payer payment amounts are required to be entered at the detail level 476 2430 SVD Line Adjudication 476 2430 SVD01 Identification Code This number should match one

occurrence of the 2330B-NM109 identifying Other Payer.

477 2430 SVD02 Service Line Paid Amount

Enter the Third Party Payment Amount (TPL) OR amount Plan Paid to provider at the line item level only. ENCOUNTER - If CN101=05, SVD02 should be 0. If CN101=09, then SVD02 should be the detail other payer paid amount OR amount Plan Paid to provider.

480 2430 CAS Line Adjustment 482- 2430 CAS02, Adjustment Reason 1, 2, 66, For Outpatient: 484 CAS05, Code A1 “1”enter the Medicare Deductible

CAS08, Amount CAS11, “2” enter the Medicare CAS14, Coinsurance Amount CAS17 “66” enter the Medicare Blood

Deductible. ENCOUNTER: "A1" - MCO Denied line item





Page

Loop ID

Reference

Name Codes/ Value

Notes/Comments

482- 2430 CAS03, Adjustment Amount 1, 2, 66 If Adjustment Group Code 485 CAS06, (CAS01)=PR and Adjustment

CAS09, Reason Code value is: CAS12, “1” enter the Medicare CAS15, Deductible Amount CAS18 “2” enter the Medicare

Coinsurance Amount “66” enter the Medicare Blood Deductible




8 Frequently Asked Questions

This appendix contains a compilation of questions and answers relative to Florida Medicaid and its providers. Please reference the following link:

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/ 66/Default.aspx.

For more information concerning remediation of Encounter claims, please refer to the Managed Care Tip Sheets at the following link:

http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Support/ tabId/78/Default.aspx?linkid=tip

NOTE For SFTP submitters only: The inbound file name should not be more than 40 characters in length including the extension. If the file is received with a file name of more than 40 characters, the system will alter the inbound file name as required to process through the EDI System.

http://portal.flmmis.com/FLPublic/Provider_EDI/Provider_EDI_SubmissionInformation/tabId/66/Default.aspx

http://www.wpc-edi.com/hipaa/HIPAA_40.asp

http://portal.flmmis.com/FLPublic/Provider_ManagedCare/Provider_ManagedCare_Support/tabId/78/Default.aspx?linkid=tip

http://www.mymedicaid-florida.com/?linkid=tip


A - 1 HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Appendix A. Financial Class Codes Crosswalk The 837I does not support the use of the Financial Class Code that is currently billed on Hospital claims. Payer Responsibility Sequences (SBR01) and Claim Filing Indicators (SBR09), which indicate the relationship each payer has to Medicaid and other payers on each claim, replaces the data supplied by the Financial Class Code. See crosswalk below for details. Financial class code crosswalk for fee-for-service ONLY:

Financial

Class Code

Description

Payer Responsibility Sequence/Claim Filing Indicator

1st

(Primary)

2nd (Secondary)

3rd

(Tertiary)

100 Medicaid as sole payer MC n/a n/a 180 Hospice with No Patient

Responsibility MC ZZ n/a

210 Medicaid with one or more TPL payers

CI MC or HM or 16

MC

510 Medicare Part A or Part C with Medicaid

MA or 16 MC n/a

910 Medicare Part B with Medicaid MB MC n/a Financial class code crosswalk for Encounter ONLY:

Financial

Class Code

Description

Payer Responsibility Sequence/Claim Filing Indicator

1st

(Primary)

2nd (Secondary)

3rd

(Tertiary)

100 Medicaid as sole payer MC n/a n/a 110 Medicaid with Medicaid HMO Plan MC MC n/a 180 Hospice with No Patient

Responsibility MC or HM ZZ MC

210 Medicaid with one or more TPL payers

CI MC or HM or 16

MC

510 Medicare Part A or Part C with Medicaid

MA or 16 MC or HM MC

910 Medicare Part B with Medicaid MB MC or HM MC NOTE: When submitting FCC 180, the "other payer" loop (2320) is required. In such cases, SBR09 should contain a "ZZ" as stated above, and the other information should mimic the payer information in the 2000B loop. See the alternative below for Hospice billing.




Note for Hospice Billing Only: FCC180, alternatively, may be reported as a patient responsibility amount within the 2300 Loop HI*BE segment where HI01-2 equals 31 and HI01-5 equals 0 dollar amount. In such cases, SBR09 should contain a "MC," and the other information should mimic the payer information in the 2000B loop.

Example: HI*BE:31:::0~


B - 1 HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Appendix B. Occurrence Codes to Replacement Codes Crosswalk

Below is a crosswalk of the current Florida-specific Occurrence Codes to Replacement Codes crosswalk for Loop 2300, HI segment (elements HI01-2 through HI12-2).

Current Code Replacement Code Description 50 Not Used Newborn - Mother not on Medicaid 51 42 Newborn - Mother on Medicaid 54 73 Medically Needy First Date of Eligibility


C - 1 HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Appendix C. Nursing Home Termination Codes to Patient Status Codes Crosswalk

Below is a code crosswalk of Nursing Home Termination codes to X12N 837I Patient Status Codes.

FMMIS Nursing Home Termination Codes X12N 837I Patient Status Codes 0 – Per Diem 30 – Still patient, State defined 1 - Hospital 09 – Transferred to hospital 2 – Return Home 01 - Discharged 3 - Death 20 – Patient died CSP 4 – Transfer to facility 03 – Transferred to SNF


D - 1 HP Confidential © 2015 Hewlett-Packard Development Company, L.P.


Appendix D. Currently Used Revenue Codes to Equivalent Standard Codes Crosswalk

Below is a code crosswalk of currently used revenue codes to equivalent standard codes for Loop 2400, SV2 segment (elements SV201).

Current Revenue

Code

Description

Standard Revenue Code

0273 Burn Pressure Garment 0273 is acceptable for use when billed with diagnosis codes 940.0 through 949.5.

0274 Cochlear Implant Handling 0278 – Other Implants 0278 Norplant Subdermal Contraceptive 0278 – Other Implants 0279 Other Supplies/Devices 0279 is acceptable for use when billed with

diagnosis codes 940.0 through 949.5. 0452 Emergency Medical Screening 0451

837i companion guide...aug 16, 2016 · version 1.2 – august 16, 2016 fmmis 837 institutional...

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