Medicaid companion guide professional
(pdf)
This companion guide has been written to
assist those who will be implementing the ASC X12N 837 Professional
Healthcare Claims Set for use with The Health Information Network
(THIN). THIN’s recommendations are noted in the comments section of
the companion document, otherwise please refer to the ASC X12N 837
(004010X098A1) Implementation Guide dated October 2002 for field
requirements. By addressing trading partner specific processing
considerations, our hope is that this companion document will
simplify your implementation.
Please note that this guide is intended only as a supplement to and
NOT a replacement for the ASC X12N 837 Professional Healthcare
Claims Implementation Guide as mandated under HIPAA. The
implementation specifications for the ASC X12N 837 Standard may be
obtained from the Washington Publishing Company, PMB 161, 5284
Randolph Road, Rockville, MD, 20852-2116; telephone 301-949-9740;
and FAX: 301-949-9742. They are also available through the
Washington Publishing Company on the Internet at
http://www.wpc-edi.com.
EDI System vendors and submitters
including individual providers who have programmed their own systems
will be required to complete a testing phase before production
status can be granted to ensure accurate format and claims data
quality. Once the vendor or submitter is granted production status,
providers can be enrolled without additional testing. We do however,
allow and recommend all submitters to submit a test file to ensure
format and syntax standards are maintained. We must be notified so
that the submitter identification number can be activated on the
testing facility.
The submitter of the test file must first test utilizing the THIN
web site ANSI testing facility at: www.thineditest.com. This
facility is a secure internet facility that allows users to test
integrity, format, syntax, balancing requirements for 4010.A1 HIPAA
transactions on their own schedule. This IS NOT a HIPAA
certification facility. THIN is in no way certifying your
transaction as HIPAA compliant. This facility is designed to ensure
THIN EDI trading partners meet the THIN claims processing
requirements only. The testing process is user friendly and
facilitates the testing process without the support of an analyst,
thereby eliminating the delays due to schedule conflicts. Once a
successful test file has been accepted with no errors, an email
message is automatically generated to the EDI Analysts. An EDI
analyst will verify the test submissions for accuracy and email the
submitter a “Connect For Success Phase I” confirmation form within
three business days.
The submitter may then proceed to the second level of testing that
includes all of the payer specific business and data content
requirements. This level of testing will be done on the rEDI-link
Blue production transmission numbers. This level of testing will
produce the rEDI-link Blue Response file that users receive today.
This level of testing may also be done without support of an
analyst. When you have a submission without rejects and are
comfortable with the results, you may email the EDI Analyst you have
been working with. An EDI analyst will verify the test submissions
for accuracy and email the submitter a “Connect For Success –
PRODUCTION” confirmation form within three business days. This will
complete your testing with THIN. We encourage vendors and submitters
to send test files any time system upgrades or changes occur.
Test files should consist of a variety of
at least 25 claims that represent the type of claims the
vendor/submitter will be submitting once production status is
achieved. Test claims will not be processed for payment but will be
validated against production files in Phase II testing, so they must
contain valid patient, procedure, diagnosis and provider
information. Since test claims will not be processed for payment,
claims previously submitted for payment or claims which have not yet
been submitted may be used.
For example, if a vendor or submitter has a provider whose specialty
is ophthalmology and he performs eye exams and cataract surgery
routinely, the test claims from this provider should include claims
for eye exams and cataract surgery, office services and ambulatory
surgical center services. If only eye exams are submitted on the
test, production status may not be achieved.
-
R (Required): This
field must always be included in the transmission.
-
S (Situational):
This field is necessary in certain situations. Please review the ASC X12N Implementation Guide for instructions on when this is
required.
-
N/U (Not Used): The
shaded areas of the Companion Guide are NOT USED according to
standards and should not be included in transmissions.
-
Comments: This
provides the THIN requirements/recommendations for some fields.
Comments: This provides
the THIN requirements/recommendations for some fields.
Until the implementation of the National Provider Identifier
—either the Tax ID or Social Security number of any provider included
in the transaction is required. This includes referring,
supervising, ordering, etc.
All dates are 8 character dates in the format CCYYMMDD. The only
date data element that is in YYMMDD is the Interchange date data
element in the ISA segment.
We recommend the use of the following delimiters in all
transactions:
|
CHARACTER |
NAME
|
DELIMITER |
|
*
|
Asterisk |
Data
Element Separator |
|
:
|
Colon |
Sub-element Separator |
|
~
|
Tilde |
Segment Terminator |
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