edi 837i 5010 companion guide - hcdpbc.org

EDI837I5010COMPANIONGUIDE

11/01/2015 Electronic Data InterchangeInstitutional Claims Companion Guide

For the Submission of Electronic Claims to:

The Health Care District of Palm Beach County and Healthy Palm Beaches, Inc.

EDI 837I 5010 Companion Guide

Contents

Purpose of this Guide ................................................................................................................................................... 1

EDI Business Requirements ......................................................................................................................................... 1

EDI Enrollment............................................................................................................................................................. 2

Clearinghouse Setup..................................................................................................................................................... 2

Data Requirements ....................................................................................................................................................... 2

File Level Validation..................................................................................................................................................... 3

Claim Level Validation and Required Information .................................................................................................. 3

Exceptions to EDI Claims Submission........................................................................................................................ 3

EDI Claims Submission Schedule ............................................................................................................................... 4

Claims Status Report.................................................................................................................................................... 4

Notice Requirements and Corrective Action ............................................................................................................. 4

EDI Claim Process Diagram ........................................................................................................................................ 5

Control Segment Definitions for Health Care District of Palm Beach County 837 Transactions ........................ 6 X12N EDI Control Segments................................................................................................................ 6

1.1 ISA - Interchange Control Header Segment ............................................................................................... 6 1.2 IEA - Interchange Control Trailer .............................................................................................................. 8 1.3 GS – Functional Group Header .................................................................................................................. 8 1.4 GE – Functional Group Trailer .................................................................................................................. 9 1.5 ST – Transaction Set Header...................................................................................................................... 9 1.6 SE – Transaction Set Trailer .................................................................................................................... 10 1.7 Valid Delimiters ....................................................................................................................................... 10

X12N 837 Business Scenarios - Inbound Transactions ........................................................................................... 11

X12N 837 Institutional Loop and Data Element Specific Information for Health Care District of Palm Beach County...................................................................................................................................................................... 13

EDI Enrollment Instructions ..................................................................................................................................... 22

Purpose of this GuideThe Health Care District and Healthy Palm Beaches has created this Companion Guide to assist our healthcare providers in understanding the steps involved for establishing electronic data interchange for claims submission. The guide contains information on who to contact, clearinghouses, and EDI requirements by the District and Healthy Palm Beaches.

The Health Care District and Healthy Palm Beaches recommend that you read this EDI guide in its entirety before getting started. Any questions should be addressed to the contacts listed in this guide.

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.

EDI Business RequirementsThe Health Care District and Healthy Palm Beaches have established a set of requirements that healthcare providers must meet before submitting electronic healthcare claims for payment. These requirements are as follows:

Establish a business relationship with a clearinghouse. Complete an Electronic Claims Enrollment form.

The Health Care District and Healthy Palm Beaches will allow providers to submit EDI files without use of a clearinghouse (direct submission). Providers will need to test submission processes with the district and be approved for this submission process. Contact the EDI team for more information.

Contact Information The Health Care District and Healthy Palm Beaches have a team of EDI professionals dedicated to assisting healthcare providers establish and maintain the EDI process. These professionals are available to answer any questions related to EDI, from initial setup and day-to-day business operations. Each member of the EDI Team has a specific area of expertise.

Provider Relations Information Claims Processing Help Desk Dept Technology Dept

866-930-1002 561-659-1270 561-659-1270 561-659-1270 Ext. 5886 Ext. 5960 Ext. 5800

Hours of Operation: Monday – Friday 9:00 am – 4:00 pm EST.

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

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

EDI Enrollment As a healthcare provider, your billing service or clearinghouse will need to contact Provider Services at the Health Care District and express interest in establishing a claims EDI business relationship. An Electronic Claims Enrollment Form included in this companion guide needs to be completed and submitted to Provider Services. Our EDI technical resource will contact the provider or billing service to start setting up the process for testing. You may reach Provider Services at (561) 659-1002.

Clearinghouse SetupMedical claims clearinghouses provide various services. Some of these services may include:

Routing healthcare claims to the appropriate destination. Validating healthcare claims before submitting to the receiver. Convert proprietary billing information generated by your system into the ANSI X12 format. NOTE: All

healthcare claims submitted to the Health Care District electronically must be ANSI 837 compliant.

The Health Care District and Healthy Palm Beaches have chosen to do business with Availity LLC and Emdeon. We encourage providers and billing services that do not have a clearinghouse to choose one of these clearinghouses. This is a free service to claim submitters.

AVAILITY EMDEON Client Services Enrollment 800-282-4548 866-924-4634

Data RequirementsThe clearinghouse, Health Care District and Healthy Palm Beaches perform data validation on your claim files. The process is done at the file level as well as claim level. Providers are required to submit complete and accurate information.

Member IDs: The member ID number is required to be a minimum of twelve numeric characters for Health Care District and eight numeric characters for Healthy Palm Beaches.

Claims submitted with the incorrect format (i.e. dashes, asterisk, etc.), will be rejected by Availity with the following rejection reason “The member ID (Loop 2010BA, Segment NM109) must be a minimum of (nine) or (six) numeric digits”.

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File Level Validation The Health Insurance and Accountability Act (HIPAA) of 1996 states that all healthcare claim files submitted electronically must be in the ANSI X12 format. The Health Care District and Healthy Palm Beaches reject all files that are not ANSI X12 compliant.

Claim Level Validation and Required InformationThe Health Care District and Healthy Palm Beaches require the following information in order to process your electronic claim file:

Patient’s name and ID number – Be sure to accurately enter the patient’s information as it appears on the patient’s ID card. The member identification number should contain numeric characters only (no dashes, asterisk, etc.).

Patient’s date of birth – Confirm that this date is correct. NPI – The National Provider Identifier must match the data on file. Federal tax ID number – This number must match the data on file in your provider contract. Taxonomy Code – Standard administrative code set for identifying the provider type and area of

specialization for all health care providers. Current medical code sets – Coding must be current for date of service and age/gender appropriate

where applicable.

● CPT – Current Procedure Terminology ● ICD-9-CM/PCS – International Classification of Diseases, 9th Edition, Clinical

Modification/Procedure Coding System ICD-10-CM/PCS – International Classification of Diseases, 10th Edition, Clinical

Modification/Procedure Coding System ● HCPCS – Health Care Procedure Coding System ● NDC – National Drug Codes National Uniform Billing Committee (NUBC) Codes (Revenue Codes)

Failure to use and submit these data elements will cause the claim transaction to be rejected back to the clearinghouse so that the transaction can be corrected and resubmitted by the provider.

Exceptions to EDI Claims SubmissionThe following claims may not be submitted electronically:

Claims with Coordination of Benefits (COB) information

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EDI Claims Submission Schedule As a provider or billing service, you may submit claims every day and at different times of the day. The Health Care District and Healthy Palm Beaches are on a set schedule with Availity and Emdeon to receive electronic claims once per day.

AVAILITY EMDEON MONDAY 4:00 AM 5:00 AM TUESDAY 4:00 AM 5:00 AM WEDNESDAY 4:00 AM 5:00 AM THURSDAY 4:00 AM 5:00 AM FRIDAY 4:00 AM 5:00 AM

Note: The Health Care District and Healthy Palm Beaches do not receive electronic claims on weekends, holidays, or at any other time of the day other than the times specified above. Claims received during holidays or weekends will be considered received as of and processed the next business day.

Claims Status ReportThe Health Care District and Healthy Palm Beaches generate a file level report as well as a claim level report in response to each claim file received. This reported information is returned the same way as the claim file was received.

277CA – An unsolicited acknowledgement of the acceptance or rejection of individual bill transactions by the claim system.

999 - Functional acknowledgment at file level that the file has been received.

Notice Requirements and Corrective ActionAll providers enrolled in the EDI Program are required to provide immediate notice to the Plan when:

Physical Address Changes

Billing Address Changes or Additions or Deletions

Tax Identification Number (TIN) Changes

NPI Changes or Additions or Deletions

Use of NPI that isn’t included on enrollment forms on record

Providers that submit electronic claims with identifiers that differ from their enrollment will receive claim rejection(s).

Failure to properly notify the Plan of physical or billing address changes, TIN changes, and/or NPI changes or additions or deletions that do not match information as found on the provider’s EDI enrollment forms will lead to corrective action steps. Corrective action includes formal notification by the Plan of submissions that do not match enrollment forms on record. Three consecutive notices for the same error may lead to disenrollment from the EDI program.

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EDI Claim Process Diagram

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Control Segment Definitions for Health Care District of Palm Beach County 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 railer TA1 - Interchange Acknowledgement

1.1 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 '00' – No Authorization Information Present

C.4 N/A ISA02 Authorization Information

[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

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C.4 N/A ISA06 Interchange Sender ID

Identifier supplied by Health Care District of Palm Beach County

C.5 N/A ISA07 Interchange ID Qualifier

C.5 N/A ISA08 Interchange Receiver 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

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1.2 IEA - Interchange Control TrailerCommunications 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


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

1.3 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.



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

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

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.

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

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1.4 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.



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.

1.5 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.



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

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.

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1.6 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.



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

1.7 Valid Delimiters The delimiters documented below are used for Health Care District of Palm Beach County, 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

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X12N 837 Business Scenarios - Inbound Transactions This section contains Payer-specific business rules and limitations for the 837 Institutional transactions.

1. Subscriber, Insured = Member

2. Provider Identification = NPI: The NPI is required on all electronic transactions. Claims that lack the NPI are rejected.

For all non- healthcare providers where an NPI is not assigned, the claim must contain the agreed-to identifier 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/999 Functional Acknowledgement:

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

Health Care District of Palm Beach County provides a 999 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 a claim transaction, i.e., 837, you will receive the unsolicited 277.

7. When NM108 = 24 or REF01 = EI:

If the NM108 equals 24 (Employer Identification Number (EIN) or the REF01 equals EI (EIN) within any loop, the value in the corresponding NM109 or REF02 must be in the format of XXXXXXXXX.

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.

9. Document Level:

Health Care District of Palm Beach County (HCDPBC) 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 by HCDPBC. Those claims that fail compliance are reported on the 999.

10. Dependent Loop:

For HCDPBC, the subscriber is always the same as the patient (dependent).

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11. Identification of TPL:

Claims with third party payment responsibility are not accepted electronically by HCDPBC at this time.

12. 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. Claims that require the NDC and do not contain the NDC code in the claim transaction will be denied and will require resubmission.

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X12N 837 Institutional Loop and Data Element Specific Information for Health Care District of Palm Beach County


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 'CH' - Chargeable (Use with Institutional Health Care Claim)

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

Qualifier 72 1000A NM109 Identification Code

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

77 1000B NM109 Identification Code

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Notes/Comments

80 2000A PRV Billing Provider Specialty Information

Health Care District does not normally require the taxonomy code. This segment should not be submitted.

80 2000A PRV01 Provider Code ‘BI’ – Billing

80 2000A PRV02 Reference Identification Qualifier

‘PXC’ – Health Care Provider Taxonomy Code

80 2000A PRV03 Reference Identification

Provider Taxonomy Code

84 2010AA NM1 Billing Provider Name

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

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Notes/Comments

Subscriber Level NOTE: For Health Care District of Palm Beach, 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 Health Care District of Palm Beach County 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

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Notes/Comments

114 2010BA NM109 Identification Code HCDPBC Member 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 Health Care District of Palm Beach County

123 2010BB NM108 Identification Code Qualifier

PI PI – Payer Identification

123 2010BB NM109 Identification Code Health Care District : 95828 Healthy Palm Beaches: 95827

125 2010BB N4 Payer City, State, Zip Code

125 2010BB N401 City Name West Palm Beach 125 2010BB N402 State or Province

Code FL

126 2010BB N403 Postal Code 33461-3133 129 2010BB REF Billing Provider

Secondary Identification

Do not submit for this segment

129 2010BB REF01 Reference Identification Qualifier

130 2010BB REF02 Reference Identification

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.

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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”.

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)

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.

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

163 2300 REF Referral Number HCDPBC does not issue referrals so this ref segment should never be submitted.

163 2300 REF01 Reference Identification Number Qualifier

9F “9F” – Referral Number

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Notes/Comments

163 2300 REF02 Reference Identification

No

164 2300 REF Prior Authorization 164 2300 REF01 Reference

Identification Qualifier

G1 “G1” – Prior Authorization


Authorization number provided by HCDPBC. Do not submit any text instruction here such as “NOT NEEDED”, etc.

166 2300 REF Payer Claim Control Number

166 2300 REF01 Reference Identification Qualifier

F8 “F8” – Original Reference Number

NOTE: The F8 qualifier should only be used when voiding or adjusting a previously paid encounter.


Enter the 16-digit claim number assigned to the original claimsubmission.

170 2300 REF Claim Identifier for Transmission Intermediaries

Follow clearinghouse instructions for this reference segment.

If submitting EDI files directly to HCDPBC, this will be your identifier that will be placed in the HCDPBC claim record and returned to you for matching payments or denials, etc.

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Notes/Comments

170 2300 REF01 Reference Identification Qualifier

D9 'D9' - Claim Number


Following clearinghouse instruction for use of this segment.

If you are submitting EDI files direct to HCDPBC, this will be your claim identifier that will be included in the HCDPBC claim record and returned to you for use in identifying your EDI claim record outcomes.

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 Provider’s Individual NPI

Rendering Provider NOTE: Required when the Rendering Provider is different than the Attending Provider reported in Loop ID-2310A of this claim. Rendering provider is normally not submitted for HCDPBC institutional claims.

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

Service Facility NOTE: Required when the location of health care service is different than that carried in Loop ID-2010AA (Billing Provider). When an organization health care provider’s NPI is provided to identify the Service Location; the organization health care provider must be external to the entity identified as the Billing Provider (for example, reference lab). It is not permissible to report an organization health care provider NPI as the Service Location if the entity being identified is a component (for example, subpart) of the Billing Provider. In that case, the subpart must be the Billing Provider.

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Notes/Comments

341 2310E NM1 Service Facility Name

342 2310E NM101 Entity Identifier Code 77 “77” – Service Location

342 2310E NM108 Identification Code Qualifier

XX “XX” – Centers for Medicare and Medicaid Services National Provider Identifier (NPI)

342 2310E NM109 Identification Code

344 2310E N301 Address Information Service Facility Location Address Line

347 2310E REF Service Facility Name Secondary Identification

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 Provider’s Individual NPI

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Notes/Comments

Service Line Number

423 2400 LX Service Line Number 423 2400 LX01 Assigned Number HCDPBC 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

425 2400 SV202-1 Product/Service ID Qualifier

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

428 2400 SV205 Quantity

Drug Identification

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

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EDI Enrollment Instructions

Step 1 Contact your existing software vendor to be certain claims can be sent through Availity L.L.C. or Emdeon.

Step 2 Page 23

Section I is required and must be filled out entirely, please list the primary facility location in Palm Beach County

Section II Indicate the name of the clearinghouse who will submit your claims

Section III Should match your UB 04 paper claims. Review a UB 04 paper claim and complete this section to match field locator 2.

Organizational NPI – indicate the organizational NPI number(s) that will be utilized in your EDI billing including subparts. Please provide the Organizational NPI number found in FL56.

Step 3 – requires an authorized signature and date.

Step 4 Fax pages 23 and 24 to Business Analytics at (561) 804-5650.

Step 5 You will receive a confirmation with the payer identification numbers via email. This confirmation is the final step. You can begin submitting electronic claims.

Maintain the EDI Companion Guide for future reference. It contains important contact information for troubleshooting.

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EDI Enrollment Request for New Submitter

(Please Print Legibly) Section I. Organization Information

Practice/Facility Name:

Address:

City: State: Zip:

Contact Name: Telephone :

Email:

Section II. Clearinghouse

Clearinghouse Name:

Contact Name: Telephone:

Email Fax:

Requested Claim Transactions: 837 INST

Section III: (FL 2 of Paper Claim)

Payee Name:

Address:

City: State: Zip:

TIN Number:

Contact Name: Telephone:

Email:

NPI Number Include all Subparts:

To complete the application, please submit a copy of your UB04.

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The undersigned hereby: Authorizes Health Care District of Palm Beach County and Healthy Palm Beaches to disclose protected

health information to the business associate identified in Section II;

Agrees to notify Health Care District of Palm Beach County and Healthy Palm Beaches of any changes in NPI, provider, address or change in Medicaid registration information as identified in this agreement.

The user of this form agrees to: 1) Use sufficient security procedures to ensure that all transmission of documents are authorized and

protect all subscriber-specific data from improper access;

2) Submit transactions that are HIPAA compliant in both formatting and coding standards; and

3) Establish and maintain procedures and controls so that information concerning Health Care District of Palm Beach County and Healthy Palm Beaches subscribers, or any information obtained from Health Care District of Palm Beach County or Healthy Palm Beaches shall not be used by agents, officers, or employees of the billing services except as provided by Health Care District of Palm Beach County and Healthy Palm Beaches.

___________________________________________________________ ___/___/___ Authorized Signature Date

PLEASE BE SURE THAT ALL INFORMATION IS COMPLETE, TRUE, AND ACCURATE.

PLEASE FAX TO BUSINESS ANALYTICS AT (561) 804-5650 OR EMAIL FORMS TO

[email protected].

NOTIFICATION WILL BE SENT THAT YOU ARE READY TO SUBMIT EDI CLAIMS.

DO NOT SUBMIT CLAIMS UNTIL YOU ARE NOTIFIED THAT SET-UP IS COMPLETE.

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mailto:[email protected]

edi 837i 5010 companion guide - hcdpbc.org

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