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Introduction ANSI X12 StandardsIntroduction to ANSI X12Standards004010Who needs to understand them?Session Objectives Standards support business activityIntroduce standards documentationIntroduce standards implementation guidelinesDevelop sample 837 transaction setNORMAL MENTCUSTSERVICECLAIMSPROCESSINGALLIANCEDETROIT MIALLIANCEDETROIT MICUSTSERVICEPresented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 1

Introduction ANSI X12 StandardsPAPER vs EDIDocument -TransactionLittle Envelope-Functional GroupBig Envelope Postal Service -InterchangeVANCourier Delivery- Point-to-PointHuman Audit Machine AuditEDI ERCHANGEEDIVANINTERCHANGEFUNCTIONALGROUPStandards LanguageDocument Line -TransactionSegmentPhrase -Composite ElementWord Code -Simple ElementIdentifierPunctuation - DelimitersGrammar SyntaxPresented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 2

Introduction ANSI X12 StandardsSIMPLE AND COMPOSITEDATA ELEMENTSN1*PR*ABC INS CO*PI*ABC47 TOO*JP*8*F:L Levels of Standards Documentation ANSI X12 Standards Documentation Industry Implementation Guidelines Trading Partner ProfilesSection I - Transaction Set TablesTable 1HeaderSTBHTTable 2DetailHLTable 3SummaryRelated informationusually appearstogether.SEPresented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 3

Introduction ANSI X12 StandardsFunctional Group ID: HC837 Health Care ClaimTable 1 – HeaderPOS# SEG ID NAME005 STTransaction Set Header010 BHT Beginning of Hierarchical TransactionREQ. DES MAX USE LOOP REPEATM1M1LOOP ID – 1000020045NM1PER10Individual or Organization NameAdministration Communication ContactOO12Table 2 – DetailPOS# SEG ID NAMEREQ. DES MAX USE LOOP REPEATLOOP ID – 2000 1001003HLHierarchical LevelPRV Provider InformationLOOP ID – 2010MO11015040NM1PERIndividual or Organization NameAdministration Communication ContactOO12555SETransaction Set TrailerM110837 Health Care Claim: ProfessionalTable 1 – HeaderPG POS# SEG ID NAME62 005 STTransaction Set Header63 010 BHT Beginning of Hierarchical TransactionUSAGERRREPEAT11LOOP ID – 1000A SUBMITTER NAME6771020045NM1PERLOOP REPEAT1Submitter NameSubmitter EDI Contact InformationRR12Table 2 – Detail – Billing/Pay-To ProviderPG POS# SEG ID NAMEUSAGEREPEATLOOP ID – 2000A der Hierarchical Level84015LOOP ID – 2010AA BILLNG PROVIDER NAMENM1 Billing Provider NameLOOP REPEAT 1R1R1R11Table 2 – Detail – Subscriber573 555SETransaction Set TrailerTransaction Set Tables Permitted segments Required order Presence requirement How many LoopsPresented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 4

Introduction ANSI X12 StandardsRECEIVER NAMENM1 Individual or Organization NameLevel: HeaderSyntax: 1. P0809If either NM108 or NM109 is present, then the other is required.NM101 98Entity IDCodeM ID 2/3*NM102 1065Entity TypeQualifierM ID 1/1*NM103 1035Name Last/Org NameO AN 1/35*NM104 1036NameFirstO AN 1/25*NM105 1037NameMiddleO AN 1/25*NM106 1038NamePrefixO AN 1/10*NM107 1039NameSuffixO AN 1/10*NM108 66ID CodeQualifierX ID 1/2*NM109 67IDCODEX AN 2/80*NM110 706EntityRelat CodeX ID 2/2*NM111 98Entity IDCodeO ID 2/3NM1 * BILLING PROVIDER NAMENM1 Individual or Organization NameLevel: HeaderSyntax: 1. P0809If either NM108 or NM109 is present, then the other is required.NM101 98Entity IDCodeM ID 2/3*NM102 1065Entity TypeQualifierM ID 1/1*NM103 1035Name Last/Org NameO AN 1/35*NM104 1036NameFirstO AN 1/25*NM105 1037NameMiddleO AN 1/25*NM106 1038NamePrefixO AN 1/10*NM107 1039NameSuffixO AN 1/10*NM108 66ID CodeQualifierX ID 1/2*NM109 67IDCODEX AN 2/80*NM110 706EntityRelat CodeX ID 2/2*NM111 98Entity IDCodeO ID 2/3NM1 * Presented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 5

Introduction ANSI X12 StandardsSEGMENT· An ordered collection of elements· Elements are variable length· Elements are delimited by element separators· Segment ends with segment terminatorN1* *Data Element Dictionary§ Listed numerically§ Same in all segments§ Data & position vary§ Length min & max§ Code lists§ Type of dataHL Hierarchical LevelHL*HL01 628HierarchID NumberM AN 1/12HL01628HL02734HL03735HL04736*HL02 734HierarchParent IDO AN 1/12*HL03 735HierarchLevel CodeM ID 1/2*HL04 736HierarchChild CodeO ID 1/1 Hierarchical ID NumberThe first HL01 1, in subsequent HL segments the value isincremented by 1.Hierarchical Parent NumberThe HL02 identifies the HL01 that is the parent of this HLsegment.Hierarchical Level Code“20” Billing Provider“22” Subscriber – Child to Billing Provider“23” Dependent – Child to SubscriberHierarchical Child Code“0” No Subordinate HL Segment“1” Additional Subordinate HL Data SegmentPresented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 6

Introduction ANSI X12 StandardsHierarchical Levels in Health Care ClaimsHL*1**20*1 Billing ProviderHL*2*1*22*0 HL*3*1*22*1 HL*7*1*22*0 Subscriber #1Subscriber #2Subscriber #3Subscriber #4Claim InformationService LinesClaim InformationService LinesClaim InformationService LinesHL*4*3*23*0 HL*5*3*23*0 HL*8*1*22*1 HL*6*3*23*0 HL*9*8*23*0 Dependent #1 Dependent #2 Dependent #3Dependent #1Claim Information Claim Information Claim InformationService LinesService LinesService LinesClaim InformationService LinesValid Element TypesAN - AlphanumericB - BinaryNn - Numeric (n decimals)R - Decimal (explicit)ID - CodeDT - DateTM - TimeAN 6/6 - Exactly 6 characters longR 7/10 - From 7 to 10 digits longLENGTHSign & decimal are not counted in length.Presented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 7

Introduction ANSI X12 StandardsQUALIFIER & VALUE· Pairs elements (qualifier & value)· Flexible transaction definitions· Reuse elementsReeseSally PetersonCHIEF FINANCIAL OFFICERReese Supply CompanyPO Box 1432Miamitown OH 45432-1432Phone (513) 725-7543Fax (513) [email protected] EVOLVE· Working papers· Three times a year· Draft standards· ANSI standards· Version & 04010ANSI - 1983ANSI - 1986Draft X12 May 89ANSI - 1992Draft X12 Oct 91Draft X12 Feb 92ANSI - 1997Draft X12 Oct 97CHANGESINVOICE· Simplify data.· Eliminate transactions.· Utilize status information rather than batch data.· Reengineer business processes.· Exchange information more frequently.Presented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 8

Introduction ANSI X12 StandardsSession Summaryü Standards are based on business requirements.ü There are multiple details to coordinate.ü One person should not make all decisions.ü The business process will change over time.Presented by EDI Partners and The Healthcare Electronic Commerce Foundation(952) 927-0784 [email protected] (501) 661-9408 [email protected] 9

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ASC X12N INSURANCE SUBCOMMITTEEIMPLEMENTATION GUIDE004010X098 837004010X098 837JUNE15, 2000IMPLEMENTATION837Health Care Claim: Professional1. The 837 transaction is designed to transmit one or more claims for each billing provider. The hierarchy ofthe looping structure is billing provider, subscriber, patient, claim level, and claim service line level. Billingproviders who sort claims using this hierarchy will use the 837 more efficiently because information that appliesto all lower levels in the hierarchy will not have to be repeated within the transaction.2. This standard is also recommended for the submission of similar data within a pre-paid managed carecontext. Referred to as capitated encounters, this data usually does not result in a payment, though it ispossible to submit a “mixed” claim that includes both pre-paid and request for payment services. This standardwill allow for the submission of data from providers of health care products and services to a Managed CareOrganization or other payer. This standard may also be used by payers to share data with plan sponsors,employers, regulatory entities and Community Health Information Networks.3. This standard can, also, be used as a transaction set in support of the coordination of benefits claimsprocess. Additional looped segments can be used within both the claim and service line levels to transfer eachpayer’s adjudication information to subsequent payers.Table 1 - HeaderPAGE #POS. # SEG. n Set HeaderBeginning of Hierarchical TransactionTransmission Type IdentificationRRR111677071020025045NM1N2PERLOOP ID - 1000A SUBMITTER NAMESubmitter NameAdditional Submitter Name InformationSubmitter EDI Contact InformationRSR1127476020025NM1N2LOOP ID - 1000B RECEIVER NAMEReceiver NameReceiver Additional Name InformationRS11LOOP REPEAT11Table 2 - Detail, Billing/Pay-to Provider Hierarchical LevelPAGE #POS. # SEG. IDNAMEUSAGEREPEAT777981001003010HLPRVCURLOOP ID - 2000A BILLING/PAY-TO PROVIDERHIERARCHICAL LEVELBilling/Pay-to Provider Hierarchical LevelBilling/Pay-to Provider Specialty InformationForeign Currency 2N3N4REFREFPERLOOP ID - 2010AA BILLING PROVIDER NAMEBilling Provider NameAdditional Billing Provider Name InformationBilling Provider AddressBilling Provider City/State/ZIP CodeBilling Provider Secondary IdentificationCredit/Debit Card Billing InformationBilling Provider Contact InformationRSRRSSS111188299102015020NM1N2LOOP ID - 2010AB PAY-TO PROVIDER NAMEPay-to Provider NameAdditional Pay-to Provider Name InformationSS11MAY 2000LOOP REPEAT 1RSS1111151

ASC X12N INSURANCE SUBCOMMITTEEIMPLEMENTATION GUIDE004010X098 837103104106025030035N3N4REFPay-to Provider AddressPay-to Provider City/State/ZIP CodePay-to-Provider Secondary IdentificationRRS115Table 2 - Detail, Subscriber Hierarchical LevelPAGE #POS. # SEG. IDNAMEUSAGEREPEAT108110114001005007HLSBRPATLOOP ID - 2000B SUBSCRIBER HIERARCHICALLEVELSubscriber Hierarchical LevelSubscriber InformationPatient 035NM1N2N3N4DMGREFREFLOOP ID - 2010BA SUBSCRIBER NAMESubscriber NameAdditional Subscriber Name InformationSubscriber AddressSubscriber City/State/ZIP CodeSubscriber Demographic InformationSubscriber Secondary IdentificationProperty and Casualty Claim NM1N2N3N4REFLOOP ID - 2010BB PAYER NAMEPayer NameAdditional Payer Name InformationPayer AddressPayer City/State/ZIP CodePayer Secondary 1N2N3N4LOOP ID - 2010BC RESPONSIBLE PARTY NAMEResponsible Party NameAdditional Responsible Party Name InformationResponsible Party AddressResponsible Party City/State/ZIP CodeSSRR1111NM1N2REFLOOP ID - 2010BD CREDIT/DEBIT CARD HOLDERNAMECredit/Debit Card Holder NameAdditional Credit/Debit Card Holder Name InformationCredit/Debit Card Information146149150015020035LOOP REPEAT 1RRS1111111SSS112Table 2 - Detail, Patient Hierarchical LevelFor purposes of this documentation, the claim detail information is presented only in the dependent level.Specific claim detail information can be given in either the subscriber or the dependent hierarchical level.Because of this the claim information is said to “float.” Claim information is positioned in the same hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BD in the subscriber hierarchical level when the patient isthe subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent ofthe subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See2.3.2.1, HL Segment, for details.PAGE #15215452POS. # SEG. ID001007HLPATNAMELOOP ID - 2000C PATIENT HIERARCHICAL LEVELPatient Hierarchical LevelPatient InformationUSAGEREPEATLOOP REPEAT 1SR11MAY 2000

ASC X12N INSURANCE SUBCOMMITTEEIMPLEMENTATION 3NTECR1CR2CRCCRCCRCMAY 2000LOOP ID - 2010CA PATIENT NAMEPatient NameAdditional Patient Name InformationPatient AddressPatient City/State/ZIP CodePatient Demographic InformationPatient Secondary IdentificationProperty and Casualty Claim NumberLOOP ID - 2300 CLAIM INFORMATIONClaim InformationDate - Order DateDate - Initial TreatmentDate - Referral DateDate - Date Last SeenDate - Onset of Current Illness/SymptomDate - Acute ManifestationDate - Similar Illness/Symptom OnsetDate - AccidentDate - Last Menstrual PeriodDate - Last X-rayDate - Estimated Date of BirthDate - Hearing and Vision Prescription DateDate - Disability BeginDate - Disability EndDate - Last WorkedDate - Authorized Return to WorkDate - AdmissionDate - DischargeDate - Assumed and Relinquished Care DatesClaim Supplemental InformationContract InformationCredit/Debit Card Maximum AmountPatient Amount PaidTotal Purchased Service AmountService Aut