HAP Midwest Health Plan HIPAA Transaction … · HAP Midwest Health Plan HIPAA Transaction ... authorization information and delimiters. ... Code HAP Midwest Health Plan ID will be

2017 © HAP Midwest Health Plan

HAP Midwest Health Plan, Inc

2850 W. Grand Blvd. Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783

COMPANION GUIDE FOR THE HIPAA 277 CLAIMS ACKNOWLEDGEMENT

VERSION 5010

HAP Midwest Health Plan

HIPAA Transaction

Standard Companion Guide

American National Standards Institute

(ANSI) ASC X12N 277 (005010X214)

Health Care Claim Acknowledgement (277CA) OCTOBER 3, 2017


VERSION 5010

2017 © HAP Midwest Health Plan HAP Midwest Health Plan, Inc. 2850 W Grand Blvd., Detroit, MI 48202 Phone (888) 654-2200 FAX (248) 663-3783

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Disclosure Statement This companion document is the property of HAP Midwest Health Plan and is for use solely in your capacity as a trading partner of health care transactions with HAP Midwest Health Plan. It is incorporated by reference in the EDI Trading Partner Agreement.

Preface This document describes the components that are related to the file for the 277CA (Claims Acknowledgement) for Professional and Institutional EDI transactions.

http://www.midwesthealthplan.com/


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EDITOR’S NOTE:

This page is blank because major sections of a book should begin on a right hand page.



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Table of Contents

Disclosure Statement ........................................................................................................... 2

Preface .......................................................................................................................................................... 2 1 INTRODUCTION .......................................................................................................... 5

SCOPE ............................................................................................................ 5 REFERENCES ............................................................................................................. 5 ADDITIONAL INFORMATION ............................................................................. 6

2 GETTING STARTED .................................................................................................... 6 WORKING WITH HAP MIDWEST HEALTH PLAN .......................................... 6 TRADING PARTNER REGISTRATION .............................................................. 6 CERTIFICATION AND TESTING OVERVIEW ................................................... 6

3 TESTING WITH THE PAYER ....................................................................................... 6 4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS ............................................. 6

PROCESS FLOWS ............................................................................................. 6 COMMUNICATION PROTOCOL SPECIFICATIONS ......................................... 7 PASSWORDS ..................................................................................................... 7

5 CONTACT INFORMATION ............................................................................................... 7 EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE ......................... 7 PROVIDER SERVICE NUMBER ..................................................................... 7 APPLICABLE WEBSITES/E-MAIL ................................................................... 8

6 CONTROL SEGMENTS/ENVELOPES ............................................................................ 8 ISA-IEA – ASC X12N 277 (005010X214) – 277 TRANSACTION INTERCHANGE

ENVELOPE AND FUNCTIONAL GROUP STRUCTURE ..................... 8 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS ........................................... 8

STC COMPOSITE AND CODE USE RULES ..................................................... 8 MEMBER ID RULES ........................................................................................ 9 MAXIMUMS/LIMITATIONS.................................................................................. 9 REJECTED TRANSACTIONS/ACKNOWLEDGMENTS .................................... 9

8 ACKNOWLEDGEMENTS AND ERROR CODES .......................................................... 9 9 TRADING PARTNER AGREEMENTS ........................................................................... 13

DISCLAIMERS .............................................................................................. 13 10 TRANSACTION SPECIFIC INFORMATION ............................................................. 13

ASC X12N 277 (005010X214) – 277 TRANSACTIONS ................................. 13

Record of Changes ............................................................................................................ 19



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1 INTRODUCTION This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that HAP Midwest Health Plan has something additional, over and above, the information in the IGs. That information can:

• Limit the repeat of loops, or segments

• Limit the length of a simple data element

• Specify a sub-set of the IGs internal code listings

• Clarify the use of loops, segments, composite and simple data elements

• Any other information tied directly to a loop, segment, composite or simple data element pertinent to trading electronically with HAP Midwest Health Plan

In addition to the row for each segment, one or more additional rows are used to describe HAP Midwest Health Plan’s usage for composite and simple data elements and for any other information. Notes and comments specify detailed information. In the example below, a note about a code value about the segment is shown.

TR3 Page #

Loop ID Segment Data Element

Data Element Name

Business Rules/Notes

47 2100B NM1 - INFORMATION RECEIVER NAME

NM101 Name Last or Organization Name

Information Receiver’s name will be returned

SCOPE

The Health Insurance Portability and Accountability Act-Administration Simplification (HIPAA-AS) requires HAP Midwest Health Plan to comply with the electronic data interchange standards for health care as established by the Department of Health and Human Services and Medicare requirements for CMS.

This document is intended for use as a companion to the HIPAA-mandated ASC X12N/005010X214 277 TR3, dated January 2007. Specific payer instructions contained in this document are provided for clarification purposes only and should be used in conjunction with the noted HIPAA TR3 published by Washington Publishing Company.

This guide should not be confused with the 276/277 Claims Status Request and Response implementation.

The 277CA transaction set is generated for a submitter who is already successfully submitting 837 claim (professional/institutional) transactions. This document contains HAP Midwest Health Plan’s specifications for the transaction set as well as contact information and key points.

REFERENCES

To obtain any or all of the HIPAA mandated 005010 ASC X12 TR3s, please visit X12’s website http://store.x12.org/store/, or Washington Publishing Company’s website http://www.wpc-edi.com


http://store.x12.org/store/

http://www.wpc-edi.com/


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To obtain Health Care Code Lists, please refer to Washington Publishing Company’s website:

http://www.wpc-edi.com/reference/ . The Washing ton Publishing Company’s website provides the Claim Status codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/ and

Claim category codes http://www.wpc-edi.com/reference/codelists/healthcare/claim-status- category-codes/ for 277 Claims acknowledgement implementation.

Visit http://www.michigan.gov/mdch/ for Michigan Department of Community Health information and instructions.

For Medicare-Medicaid updates refer to http://www.cms.gov/

For Core Rules HIPAA 5010 updates refer to information on http://www.caqh.org/COREv5010.php

ADDITIONAL INFORMATION

Additional information will be provided to trading partners upon request.

2 GETTING STARTED WORKING WITH HAP MIDWEST HEALTH PLAN

277CA is the unsolicited electronic claim acknowledgement in ASC X12N 5010 x214 format. The transaction identifies claims that are accepted as well as claims that were rejected along with claim status codes that indicate the errors. Claims acknowledgement transaction set will be generated along with the 5010 999 Acknowledgement transaction set for trading partners that submit V5010 EDI transactions. In addition, HAP Midwest Health Plan will continue to return the EDI Claim Errors report.

To receive more information or ask questions, please contact Customer Service at 888-654-2200. HAP Midwest Health Plan website www.midwesthealthplan.com/ContactUs.aspx lists additional contact information.

A 277CA acknowledgement is not a guarantee of payment. The status information provided is based on the claim’s characteristics at the time the claim transactions are processed.

TRADING PARTNER REGISTRATION

Providers must complete a HAP Midwest Health Plan Trading Partner Agreement (TPA) prior to submitting V5010 EDI transactions.

CERTIFICATION AND TESTING OVERVIEW

HAP Midwest Health Plan does not require or provide certification for its trading partners.

3 TESTING WITH THE PAYER 277 Claims Acknowledgement implementation will be tested with new trading partners as part of the 5010 EDI transactions submissions testing. Trading Partners should submit test files containing a minimum of 25 test claims that accurately represent the type of claims that will be submitted in production.

4 CONNECTIVITY WITH THE PAYER/COMMUNICATIONS PROCESS FLOWS


http://www.wpc-edi.com/reference/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-codes/

http://www.wpc-edi.com/reference/codelists/healthcare/claim-status-category-codes/



http://www.michigan.gov/mdch/

http://www.cms.gov/

http://www.caqh.org/COREv5010.php

http://www.midwesthealthplan.com/ContactUs.aspx


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To receive the 277 Claim Acknowledgement transactions you must be a registered user with a password and already be submitting HIPAA-compliant 837 files (professional and/or institutional) directly to HAP Midwest health Plan.

COMMUNICATION PROTOCOL SPECIFICATIONS

Please refer to the HAP Midwest Health Plan Providers Administrative Manual for information regarding:

- Submitter setup and trading partner B2B testing

- Direct upload to HAP Midwest Health Plan using HTTPS secure file upload

- Secure FTP submission

- Interchange Acknowledgement (999) transaction

PASSWORDS

HAP Midwest Health Plan requires a password to submit requests. The password could be set up after trading partner agreements have been signed.

5 CONTACT INFORMATION EDI CUSTOMER SERVICE AND TECHNICAL ASSISTANCE

Technical assistance will be provided upon request. For questions regarding 277CA transactions, please send email to [email protected] and type in “edi277CA” as the prefix in the Subject field for expedited assistance.

PROVIDER SUPPORT NUMBER

HAP Midwest Health Plan: (313)-664-8763

APPLICABLE WEBSITES/E-MAIL

HAP Midwest Health Plan website www.midwesthealthplan.com

Additional contact information is listed at http://www.midwesthealthplan.com/ContactUs.aspx

837 Institutional

Claims

HAP MIDWEST HEALTH PLAN

837 Professional

Claims


mailto:[email protected]


http://www.midwesthealthplan.com/ContactUs.aspx


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6 CONTROL SEGMENTS/ENVELOPES ISA-IEA – ASC X12N 277 (005010X214) – 277 TRANSACTION INTERCHANGE ENVELOPE AND FUNCTIONAL GROUP STRUCTURE

This section describes HAP Midwest Health Plan’s use of the interchange control segments. It includes a description of expected sender and receiver codes, authorization information and delimiters.

TR3 Page

#

277 Loop ID

277 Segment

277Data Element

277 Data Element Name


C.4 ISA ISA – Interchange Control Header

ISA05 Interchange ID Qualifier

“ZZ” will be shown


ISA06 Interchange Sender ID

ID that corresponds to the Receivers ID on the 837 will be present


ISA07 Interchange ID Qualifier

“ZZ” will be shown


ISA08 Interchange Receiver ID

Sender ID that is on the corresponding 837 will be shown


ISA15 Usage Indicator “P” for production/”T” for test

C.7 GS GS – Functional Group Header

GS02 Application Sender’s Code

HAP Midwest Health Plan ID will be present

C.7 GS GS – Functional Group Header

GS03 Application Receiver’s Code

ID mutually agreed for transmissions will be shown

C.9 GE GE – Functional Group Trailer

GE01 Number of Transaction Sets Included

Total number of transaction sets included in the functional group will be listed

C.9 GE GE – Functional Group Trailer

GE02 Group Ctrl Number The number sender assigned is shown

HAP Midwest Health Plan’s utilizes the following characters as delimiters on outgoing 277CA transactions.

Delimiters/Separators Character Description

Asterisk * Data element separator

Carat ^ Repeating data element separator

Colon : Composite data element separator

Tilde ~ Terminator

7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS STC COMPOSITE AND CODE USE RULES

HAP Midwest Health Plan supports the following use of composites and codes within the STC segment. The STC segment contains the composite of three STCs, STC01, STC10 and STC11.

• STC01 is required and displays the Acknowledgement Code Status code and entity codes as they apply.



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• STC10 and STC11 are situational and provide additional clarification to STC01 displaying additional status and entity codes. For example, when Billing Provider’s NPI is not valid, the status codes will be shown utilizing STC10-1, STC10-2 and STC10-3 fields. STC*A7:21*20140825*U*1469.25******A7:562:85~

• Multiple STC segments will be reported for unrelated status codes

MEMBER ID RULES

Member ID is 10 digits Beneficiary ID for MEDICAID, Healthy Michigan Plan and ABW members (0012345678), 9 digits ID for HAP Midwest Advantage Medicare members (000991234), 9 digits ID for Wayne County Health Choice Members (120012345), and alpha-numeric ID for Macomb Care Connect (B0502001).

MAXIMUMS/LIMITATIONS This implementation is intended to support use in batch mode.

REJECTED TRANSACTIONS/ACKNOWLEDGMENTS

Transactions that contain an unauthorized submitter identification number, invalid submitter/provider combinations or are HIPAA non-compliant are rejected and 999 transaction(s) will be returned as defined in the 837 EDI process. The 999 transaction(s) will specify the rejection with error code(s).

8 ACKNOWLEDGEMENTS AND ERROR CODES Rejection Criteria/Error Messages on the 277CA Acknowledgement

Code Claim Status Category Description

A0 Acknowledgement/Forwarded-The claim/encounter has been forwarded to another entity. A1 Acknowledgement/Receipt – The claim/encounter has been received.

A2 Acknowledgement/Receipt – The claim/encounter has been received.

A3 Acknowledgement/Returned as unprocessable claim – The claim/encounter has been rejected. The claim must be resubmitted.

A4 Acknowledgement/Not Found – The claim/encounter cannot be found

A6 Acknowledgement/Rejected for Missing Information – The claim/encounter is missing the information specified in the Status details and has been rejected

A7 Acknowledgement/Rejected for Invalid Information – The claim/encounter has invalid information as specified in the Status details and has been rejected.

A8 Acknowledgement/Rejected for relational field in error.



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Rejection Criteria/Error Messages on the 277CA Acknowledgement


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Claim Status Code Description

A Code STC01-1

277 Status Code STC01-2

Entity/ Status Code STC01-3

Additional Status Code STC10-2

Additional Entity/Status Code STC-10-2

Invalid PCDCD A7 21 454

Invalid PCDCD Modifier A7 21 453

Invalid PCDCD Date A7 21 454

Missing PCDCD Qualifier A6 21 454

Missing Rev Code A6 21 455

Missing HCPC Code A6 21 454

Invalid Service Line A7 21 247

Invalid Vendor Address A7 21 126 87

Missing Procedure Code A6 21 454

Invalid Diagnosis Code A7 21 255

Invalid Diagnosis Code Date A7 21 557

Missing Provider NPI A6 562 85

Missing Provider Tax ID A6 128 85

Missing Provider DOS A6 187

Billing Provider Not Found A7 26 85

Rendering Provider Not Found A7 26 82

Place Of Service Or Encounter Reason Not Found

A7 21

A7 249

Multiple Members Found A8

Member Not Found A7 32

Too Many Services (999) A7 121

Too Many PCDCDE (36) A7 121

Missing or Invalid Diagnosis Code Pointer

A7 477

Plan Type Frequency Code Mismatch

A8

PCDCD Quantity less than 1 A7 476

Service Date in Future A7 510 187

Missing or Invalid Ambulance Transport Info - CR1

A6 21

266

External cause of injury invalid as primary diagnosis

A7 21

255

Invalid Quantity A7 476

Billing Provider NPI Not Valid A7 21 562 85



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A Code STC01-1





Rendering Provider NPI Not Valid A7 21 562 82

Referring Provider NPI Not Valid A7 21 562 DN

Invalid Admission/Discharge Hour A7 21 230 233

Invalid NDC Unit Code A7 21 218

Duplicate PCDCD Modifier A7 453

Missing PCDCD Modifier A6 21 453

Attending Provider NPI Not Valid A7 21 562 71

Missing Attending Provider NPI A6 21 562 71

Missing Attending Provider A6 132 71

Admission Date In Future A7 510 189

Invalid Admission Date A7 21 189

Missing Rendering Provider Name A6 21 125 82

Operating Provider NPI Not Valid A7 21 562 72

Other Operating Provider NPI Not Valid

A7 21

562 72

Missing Attending Provider Name A6 21 125 71

Facility Zip must be 9 digits A7 21 500 FA

Billing Provider Zip must be 9 digits

A7 21

500 85

Facility Address Required A6 21 126 77

Service Facility NPI Not Valid A7 21 562 77

Mixed ICD Diagnosis Versions A7 21 557

ICD-9 Code billed after ICD-10 GoLive Date

A7 21

557

ICD-10 Code billed before ICD-10 GoLiveDate

A7 21

557

Missing Diagnosis Qualifier A6 21 754 255

Only 1 rendering allowed per claim

A7 732

170 82

Admission Type not Valid for Inpatient Claim

A7 250

V-code not valid as primary diagnosis

A7 21

254

Inpatient claim must have admit date

A6 21

189

Principle diagnosis missing A6 21 255



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A Code STC01-1





Surgical Code Not Valid A7 21 666

Admit Date Cannot be in the Future

A7 510

188

Procedure Quantity Cannot be Blank

A7 476

Claim still in process over 99 lines A1 277 PR

Discharge Date cannot be in the future

A7 510

190

Invalid Discharge Date A7 21 190

Inpatient claim must have admit date

A7 21

189

Detail Line Total does not equal total submitted charges

A7 21

178

Adjudication errors A7 710

Diagnosis not enough digits A7 21 255

G/L Distribution Code not found – System Error

A8 33

Price Category/Modifier not Found

A7 21

453

Multiple Providers Found A8

Contract History Record is Expired A7 29

Claim Contains Over 26 Duplicate Procedures on the Same Day

A7 54



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9 TRADING PARTNER AGREEMENTS An EDI Trading Partner is defined as any provider, billing service or clearing house that transmits to and receives electronic data from HAP Midwest Health Plan.

HAP Midwest Health Plan has EDI Trading Partner Agreements that accompany the standard implementation guide to ensure the integrity of the electronic transaction process. The Trading Partner Agreement is related to the electronic exchange of information, whether the agreement is an entity or a part of a larger agreement, between each party to the agreement.

DISCLAIMERS

This document has been prepared as a HAP Midwest Health Plan specific companion document to ASC X12N 277 (005010X214) implementation guide and to provide instructions to trading partners for the data elements. This companion guide document supplements, but does not contradict any requirements in the implementation guide.

10 TRANSACTION SPECIFIC INFORMATION ASC X12N 277 (005010X214) – 277 TRANSACTIONS

The following section addresses specific information HAP Midwest Health Plan will return within the ASC X12N 277 (005010X214) 277 Transaction. This information should be used in conjunction with the ASC X12N 277 (005010X214) 277 TR3.

TR3 Page

#

277 Loop

277 Segment

277Data Element

277 Data Element Name


38 2100A NM1 - INFORMATION SOURCE NAME

NM101 Entity Identifier Code

‘PR” will be returned



“HAP MIDWEST HEALTH PLAN.

INC” will be returned


NM108 ID Code Qualifier

“PI” will be returned


NM109 Identification Code

“MHP77” will be returned

40 2200A TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER

TRN02 Reference Identification

Unique trace number that identifies transaction will be returned



“41” will be returned



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Information receiver’s name will be returned

48 2100B NM1 – INFORMATION RECEIVER NAME

NM108 ID Code Qualifier


48 2100B NM1 - INFORMATION SOURCE NAME


Information receiver’s primary identifier will be returned

49 2200B TRN - TRANSMISSION RECEIPT CONTROL IDENTIFIER


Value submitted in the BHT03 data element from 837 is returned

51 2200B INFORMATION RECEIVER APPLICATION TRACE IDENTIFIER

STC01-1 Health Care Claim Status Category Code

A1 = Acknowledgement/Receipt- The claim/encounter has been received. This does not mean that the claim has been accepted for adjudication.



19 = Entity acknowledges receipt of claim/encounter



“41” will be returned to indicate submitter


STC02 Date Status information effective date will be shown


STC03 Action Code “WQ” for Accept which is the default value representing transaction level acceptance. Specific rejections/acceptance will be reported in Loop 2200D. If the entire transaction set is rejected “U” will be returned.


STC04 Monetary Amount

Monetary sum of all claims within ST-SE transaction set

55 2200B QTY – TOTAL ACCEPTED QUANTITY

QTY01 Quantity Qualifier


55 2200B QTY – TOTAL ACCEPTED QUANTITY

QTY02 Quantity Total accepted quantity

56 2200B QTY – TOTAL REJECTED QUANTITY


“AA” will be returned

56 2200B QTY – TOTAL REJECTED QUANTITY

QTY02 Quantity Total rejected quantity for information receiver (not created if all claims are accepted)



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57 2200B AMT - TOTAL ACCEPTED AMOUNT

AMT01 Amount Qualifier Code

“YU” = In Process (not created when all claims are

rejected)

57 2200B AMT - TOTAL ACCEPTED AMOUNT

AMT02 Monetary Amount

Total accepted amount

58 2200B AMT - TOTAL REJECTED AMOUNT

AMT01 Amount Qualifier Code

“YY” = Returned (not created when all claims are

accepted) 58 2200B AMT - TOTAL

REJECTED AMOUNT

AMT02 Monetary Amount

Total rejected amount

61 2100C NM1 – BILLING PROVIDER NAME


“85” Billing Provider

62 2100C NM1- BILLING PROVIDER NAME

NM108 Identification Code Qualifier

“XX”

62 2100 NM1 – BILLING PROVIDER NAME

NM103 & NM104

Name Last or Organization Name & Name First

Providers name NM104 is used when Provider is Type 1

62 2100C NM1 - BILLING PROVIDER NAME


National Provider ID will be returned

64 2200C TRN - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

TRN01 Trace Type Code

“1” will be returned to indicate current transaction numbers

64 2200C TRN - PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER


Reference information as defined for a particular transaction set

65 2200C STC - BILLING PROVIDER STATUS INFORMATION

STC01-1 HEALTH CARE CLAIM STATUS

See Rejection Criteria/Error Messages on the 277CA Acknowledgement



See 277 codes on http://www.wpc- edi.com/reference/



“41” will be returned for submitter


STC03 HEALTH CARE CLAIM STATUS

“U”/”WQ will be returned to indicate rejected/accepted


STC04 HEALTH CARE CLAIM STATUS

Monetary amount will be indicated



“QA” – Total Accepted Quantity/”QC” – Total Rejected Quantity will be returned

72 220C STC - BILLING PROVIDER

QTY02 Quantity Quantity that was rejected/quantity that was






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STATUS INFORMATION

accepted will be returned


AMT01 Quantity Qualifier

“YU” – In process / “YY” – Rejected will be returned as appropriate

77 2100D PATIENT NAME NM101 Entity Identifier Code

"QC" will be returned

77 2100D PATIENT NAME NM102 Entity Type Qualifier

"1" will be returned

77 2100D PATIENT NAME NM103 Name Last or Organization Name

Subscriber's Last Name

77 2100D PATIENT NAME NM104 Name First Subscriber's First Name 2010BA NM105

78 2100D PATIENT NAME NM108 Identification Code Qualifier

“MI” will be returned

78 2100D PATIENT NAME NM109 Identification Code

Patient Identification Number is returned

79 2200D TRN – CLAIM STATUS TRACKING NUMBER

TRN01 Trace Type Code

“2” – Referenced transaction trace numbers

79 2200D TRN – CLAIM STATUS TRACKING NUMBER


Patient control number will be returned

80 2200D STC- CLAIM LEVEL STATUS INFORMATION

STC01-1 Industry Code See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement


STC01-2 Industry Code See 277 Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement


STC01-3 Entity Identifier Code

‘41’ will be returned to indicate entity associated with the claim.

See Entity/Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement


STC10-1 Health Care Claim Status Code

See A-Codes in section Rejection Criteria/Error Messages on the 277CA Acknowledgement



See Additional Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement


STC10-3 Entity Identifier Code

See Additional Entity/Status Code in section Rejection Criteria/Error Messages on the 277CA Acknowledgement



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85 2200D REF- PAYER CLAIM CONTROL NUMBER

REF01 Reference Identification Qualifier

“1K” for Payer’s claim number will be returned.

85 2200D REF- PAYER CLAIM CONTROL NUMBER

REF02 Reference Identification

Payer claim control number will be returned.

86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES


“D9” will be returned when a clearing house tracking number is received in 837

86 2200D REF – CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES


Clearing house tracking number is returned if received in 837

87 2200D REF- INSTITUTIONAL BILL TYPE IDENTIFICATION


“BLT” will be returned to indicate Institutional Bill Type identifier (Applies to Institutional claims)

87 2200D REF - INSTITUTIONAL BILL TYPE IDENTIFICATION


Institutional Type of Bill received on the claim will be returned (Applies to Institutional claims)

87 2200D DTP - CLAIM LEVEL SERVICE DATE

DTP01 Date/Time Qualifier

“472” indicating Service will be returned


DTP02 Date Time Period Format Qualifier

D8/RD8 depending if the service period is a date or range of dates


DTO03 Date Time Period

Service date

90 2220D SVC - SERVICE LINE INFORMATION

SVC01 Composite Medical Procedure

This field will be populated with the values received from 837 Professional or 837 Institutional Service Line Information when service line has an error. The following fields will indicate associated errors.

94 2220D STC- SERVICE LINE LEVEL STATUS INFORMATION



95 2220D STC- SERVICE LEVEL STATUS INFORMATION





Entity Code ‘41’ – Submitter will

be returned. See Additional Entity/Status Code in section Rejection Criteria/Error



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Messages on the 277CA Acknowledgement










99 2220D REF- SERVICE LINE ITEM IDENTIFICATION


Present only when service line has error(s). Line item control number will be returned

101 2220D DTP - SERVICE LINE DATE

DTP01 Date Time Period

Present only when service line has error(s). Service line date or date range will be returned



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Record of Changes

Version

Number

Date

Author/Owner

Description of Change

1 07/8/2014 HAP Midwest Health Plan

Document created for testing with trading partners

2 10/10/2014 HAP Midwest Health Plan

Document revised to include additional error codes


Documents

HAP Midwest Health Plan HIPAA Transaction … · HAP Midwest Health Plan HIPAA Transaction ... authorization information and delimiters. ... Code HAP Midwest Health Plan ID will be