EDI PRESENTED BY: MATT DOBRY, ELDORADO CHARLEEN MULLANEY, HEALTH PLANS INC. AND JEREMY FELDBRUEGGE,...

EDI

PRESENTED BY: MATT DOBRY, ELDORADOCHARLEEN MULLANEY, HEALTH PLANS INC.

AND JEREMY FELDBRUEGGE, BENEFIT PLAN ADMINISTRATORS

AG E N DA• 278 Transactions

Process Overview

• 834 Transactions

FAQs

• 835 Transactions

Process Overview

• 837 Continue Searching

• 837 Provider/Patient Matching

by Entity

• X12 Customization Flags

New Flags

278 TRANSACTIONS -EPISODES -REDUCE MANUAL ENTRY-UTILIZE WORKFLOW

2 7 8 S E TT I N G S• Site File driven – no fee required

• About 2 hours of training

• New flags have been added to the Entity Maintenance screen

• New 278 find program (m9278int)

• Workflow was enhanced to now have a new Rule Set: Epis(O)de

• 22 new keywords were added for the new Episode Rule Set

• Sample 278 test file

2 7 8 – E D I E N T I T Y M A I N T E N A N C E

New flags have been added to the Entity Maintenance

screen S = SSNC = Cert

Not Found and Pend Reasons

2 7 8 – LO O KU P P R O G RA M

New 278 find program (m9278int)

2 7 8 – W O R K F LO W C H A N G E S

New Workflow Rule Set: option Epis(O)de

• Utilize workflows to manage Episodes…to approve

or deny

2 7 8 – W O R K F LO W C H A N G E S

22 New keywords have been added for 278 Episode

Processing

2 7 8 – W O R K F LO W C H A N G E S22 New keywords have been added for 278 Episode Processing

2 7 8 – S A M P L E F I L E

2 7 8 – E P I S O D E C H A N G E STwo new fields and menu options will now appear in your Episode Records screen:

2 7 8 – E P I S O D E C H A N G E SSelected option: (2)78 from the Episode screen will display the File details. Action field has also been added…

2 7 8 – E P I S O D E C H A N G E SSelected option: ACTION from the command line will allow you to approve/deny episode

2 7 8 – E P I S O D E C H A N G E SSelect option: (Q)ue from the command line will allow you to approve/deny episode

834 TRANSACTIONS

-FAQ’S

• Q: What format options do we have for importing

eligibility into Eldorado?

• A: Clients have two different ways of importing

eligibility

• X12 Manager (834 transactions)

• Eligibility Import/Export (m9impexp – non HIPAA

compliant) program.

• The EDI team handles the X12 834 inquiries and our

Admin team handles the custom Eligibility

Import/Export program inquiries. You can refer to

Online Help for the m9impexp file layout: FAQ

tab>Categories>HEALTHpac 4

• For the 834 Companion Guides click ‘FAQ’

tab>COMMON INTEREST>X12 Manager Info: link,

there you will find 4010 and 5010 X12 Transaction

Sets & Data Elements – the Clients can send this info

to their vendor).

• Q: When I try to enter into the Maintain Entity/Cross

Reference table(s) I receive a red screen indicating

the file was not found, how do I rectify?

A: When a Client receives this red screen it means

the file for those tables were not built in the system.

You’re able to create these files using Online Help to

create DB/C and index commands.

• X12 Manager > X12 Supervisor Set Up

> Click here for details link

• Q: How do I know what imported into the system?

A: There is the HIPAA log(‘logs’ folder) and the

discrepancy report (‘f’ directory). These reports will

contain all the information you need to know on

what member(s)/dependent(s) were loaded into the

system and what errors were generated.

The HIPAA log will show the details of any X12

related errors.

The discrepancy report will show the details of any

updates/changes generated by the 834.

• Q: What is the 834 matching criteria (EE & dependents)?A: The employee matching process for an inbound 834 file compares the SSN/Cert number in the file against an employee in HP4. For dependents, the matching process looks at the date of birth, SSN, cert number and relationship code for all dependents in a family in HP4. Points are then assigned based on these matches:

Date of Birth = 100SSN = 100Gender = 10Relationship = 10First Name:

Exact = 55Hash Partial = 20Hash Exact = 50

The dependent with the most points is selected as the match. Dependents must have at least 100 points to be considered as a possible match. Also, if multiple dependents tie with the highest amount of points in a family, a dependent will not be selected.

Note: Inbound 834 files do not read the EDI Patient Matching Rules

Further detail of how a dependent chose:• If the request is for a dependent (and the employee has already been

identified), a check is made to see if a record already exists for this dependent. All existing dependent records will be examined. For the following fields, if the HIPAA variable and the corresponding dependent variable are both populated and contain different values, the dependent is discarded as a possible match: date of birth, dependent SSN, relationship to employee, and gender. For those dependent records that remain, points are given for exact matches: 100 for date of birth, 100 for SSN, 10 for relationship to employee, and 10 for gender. Additional points are used for matching the first name: 55 for an exact match, 50 for a Metaphone exact match, and 20 for a Metaphone partial match. The total number of points awarded to a dependent record must be at least 100 for the record to be considered a match. If no "winner" is found, the dependent-related data will be copied to a blank dependent record, and a flag will be set to note this. In addition, the number of dependents recorded in the employee record will be incremented. If the dependent was found, fields in the request are examined, variables in the dependent record are updated, and so on. Note: when updating an existing dependent record, the one with the highest number of points is used unless there is a tie

• Q: Can you please explain “hashing”?

A: Hashing rarely happens during the inbound 834 matching process, but if you find that a dependent should/should not have matched (can’t make sense of it), we can send it to our development team to debug. If you want to know more about this strictly technical term “metaphone hashing”- read the following: http://en.wikipedia.org/wiki/Metaphone

• Q: I imported the 834 file into the system, but didn’t mean to – can I extract that information out of the system?

A: No, 834 files do not work like claim (837) files. We do not have a program to delete everything that was imported, like we have for claims (i.e. m9delbch). If the Client accidently imported a file they shouldn’t have, then they have to manually make those changes back to what it was prior to importing.

http://en.wikipedia.org/wiki/Metaphone

http://en.wikipedia.org/wiki/Metaphone

• Q: Can you please explain the ‘HP errors:’ field on the HP4 HIPAA 834 Inbound screen?

A: The possible values are ‘0’ or a ‘1’‘0’ means no changes were made (Discrepancy report was not created)‘1’ means changes were made (Discrepancy report was created)

• Q: I imported an 834 file and now there are two records for my dependent, why?

A: If the vendor changed the dependent’s SSN or DOB, then according to the matching criteria those are two different people and will add an additional record. If the SSN/DOB needs to be corrected, then that has to be done manually in HP4.

• Q: I imported an 834 file containing an INS04(Maintain Reason Code) which is translated in the Maintenance Reason Code giving Employee and Dependent an Active Status, why does my Dependent Status list SCHOOL?

A: The INS09(Student Status) value will override the INS04 translation. The solution would be to have the vendor send an ‘N’ Not a Student, or not pass INS07 and beyond.

• Q: I imported the 834 file, but nothing updated in HP4, why?

A: First and foremost, check the file! If certain segments in the file are set to “Verify” then the file is a compare/audit file and those segments need to be changed by the vender. Only the HIPAA log and the discrepancy report will update, not the system. Example: BGN08 = 4 (Verify), should be 2 (Change/Update)INS03 = 030 (Audit or Compare), should be 001 (Change)HD01 = 030 (Audit or Compare), should be 001 (Change)

• Q: What does the ‘Accept request to terminate all benefits’ field do (on the Input Control screen)?

A: "Accept request to terminate all benefits" flag is there to restrict terminations done through only DTP*357 in loop 2000.

• Q: A vendor is unable to pass the REQUIRED Loop 2300, segment REF*1L ‘Plan ID’

A: When the Plan ID cannot be passed, the member will be updated but not the coverage, and the error message “Missing policy ID in health coverage data’ will be generated in the Discrepancy report. A DEFAULT Plan ID can be established in the X12 / EDI Maintain Entity / Plan Cross Reference.

• Q: Why is the member’s SSN not extracting to segment NM109 (Loop 2100A)?

A: Check the Entity Maintenance (second screen) to see if the ‘Restrict SSN/Cert Use?’ field is set to “Y”. If the vendor needs the SSN in NM109, then that flag needs to be set to “N” so it’s not restricted. There is also a ‘Restrict SSN/Cert?’ field on the Global Controls.

• Q: How do I get the SSN (or Cert) to write to the REF segments in Loop 2000?

A: That’s handled by the ‘834 subscr/client no’ field in the Entity Maintenance (second screen). If the 834 subscriber = S/client no = C, then the SSN will write to REF*0F and the Cert will write to REF*23.

• Q: How do I get an Alternate ID to write to HEALTHpac?

A: An Alternate ID can be passed in Loop 2000 REF*Q4 (Prior Identification Number) to update Alt ID 2 or REF*ZZ (Mutually Defined) to update Alt ID 1.NOTE: This function applies to members but not dependents. If these segments are passed for dependents, the dependents Alt ID’s will not be updated. The Alt ID’s loaded manually to dependents are used for search selection only.

• Q: The vendor requires sequence codes on the file, but they are only attaching to the SSN (not the Cert) – is this correct?

A: Yes, turning the ‘Add Sequence’ field to “Y” when generating an outbound 834 file will only write to SSNs, not Cert numbers. However, if you import a file with sequence numbers it does not update any eligibility, those sequence codes need to be removed from the inbound file to update.

• Q: The vendor can only accept one 834 file with all groups, what happens when the batch size exceeds 9999?

• A: If the file exceeds 9999, then a second 834 file will generate. If you set the ‘Batch size’ field on the outbound parameters screen to -1, then all groups will write to one file, no longer creating the second file.

• Q: The records are loading but the coverage screen is missing the plan data and effective date?

• A: The coverage level code(HD05) has not been added to the Miscellaneous Table Maintenance in the X12 manager(this xref table only works for inbound files). Also, verify HD01(maint. Code) matches INS04(maint. Code).

• Q: Why is the HD segment (Loop 2300 - Health Coverage) missing from my outbound 834 file?

A: The HD segment will only write to the file if the following dates in the system align: Group’s Effective Date, the Benefit Plan’s Effective Date and the Coverage Effective/Begin Date.

Example: If the Group is effective on 12/01/2012 and the Plan becomes effective until 01/01/2013, then the HD segment will not write because you’re offering a plan that is not effective yet.

• Q: Can the id card selection flag and id card format be updated by an inbound 834?

• A: Yes, using the IDC segment in loop 2300 these flags can be updated. See document ‘Default ID Card format.docx’ in this same folder

• Q: Why does the 2008 record write to the file and not the current 2012 date for my MM product?

A: If the benefit plan or coverage level did not change from 2008 to 2012, then our system will write out the true effective date for your MM product, which would be the 2008 date.

• Q: The vendor is requesting only one transaction (ST-SE) set for an entire group, instead of each member in their own set, can that be done?

A: The HP4 system does not send out only one (ST-SE) transaction set for the members/dependents in the outbound 834 file by default. All members/dependents will each have their own transaction set.However, if the ‘834 outbound: Enable Blue Cross Blue Shield (BCBS) flag?’ is set to “Y” then only one (ST-SE) transaction set is sent out.

NOTE: The functionality for a single ST-SE transaction set also requires Group Translation. Further documentation available.

835 TRANSACTIONS

C R E AT E E N T I T Y , S E T T H E F L AG F O R 8 3 5 C L A I M PA Y M E N T F I E L D :

C R E AT E E N T I T Y , S E T T H E 8 3 5 I D S F I E L D :

F L A G T H E P R O V I D E R ( S ) , F R O M W I T H I N T H E P R O V I D E R M A S T E R S E L E C T / , O P T I O N S , ( I ) A D D I T I O N A L I N F O R M A T I O N . C A N A L S O B E S E T U P A T G L O B A L L E V E L .

O N C E T H E E N D O F D A Y P R O C E S S H A S B E E N C O M P L E T E D , Y O U M A Y T H E N A C C E S S T H E X 1 2 M A N A G E R T O C R E A T E T H E 8 3 5 F I L E .

G E N E RAT E E L E C T R O N I C E O B ’ S I N H I PA A 8 3 5 F O R M AT:

8 3 5 F I L E E X A M P L E

ST*835*0001~BPR*I*19.37*C*CHK************20100306~TRN*1*1020*1123456789~DTM*405*20100306~N1*PR*DISNEY SHOP~N3*5451 N BELLEVUE DR~N4*PHOENIX*AZ*85019~REF*2U*123456789~N1*PE*THE WALSH MEDICAL CENTER*FI*123456789~N3*PO BOX 548~N4*PHOENIX*AZ*85016~LX*1~CLP*0*1*90*19.37**15*20500514900*11*1~NM1*QC*1*MARZ*JOHNNY****MI*578751245~NM1*82*2*JOHNNY WALSH*****FI*123456789~REF*1L*055DIS~SVC*HC:99001*90*19.37**1~DTM*472*20050101~CAS*PR*2*8.30~CAS*CO*8*62.33~SE*21*0001~

837 CONTINUE SEARCHING

C O N T I N U E S E A RC H I N G O N 8 3 7 When do we use the ‘Continue Searching on 837’ flag?This feature is used when EDI claims are rejected by a specific network, the system will automatically move the claims to the next available network (based on benefit plan rules: Hierarchy, Provider location or Employee location). The location information is set in the plan on the network.

Claims can be sent to multiple EDI entities…..

C O N T I N U E S E A RC H I N G O N 8 3 7 – E X A M P L E

For this one particular example, benefit plan is set up for Provider Location by State

C O N T I N U E S E A RC H I N G O N 8 3 7 - E X A M P L E

C O N T I N U E S E A RC H I N G O N 8 3 7 – E X A M P L E

What happens when all of the networks reject the claim?

System will then price based on your out of network penalty rules…..

C O N T I N U E S E A RC H I N G O N 8 3 7 - E X A M P L E

PROVIDER MATCHING AT THE ENTITY LEVEL ENHANCEMENT 4.11.01

You have the ability to view how the points were assigned to the patient when the claim is imported electronically: Patient Points lookup by HCFA(includes dental) or UB – m9patlkFirst you can review the points you have assigned: m9edifnd>/>A

• Next run ‘m9patlk’ via the programmer’s utility

• Enter claim number• Print to view

You have the ability to view how the points were assigned to the provider when the claim is imported electronically: Provider Points lookup – m9prvlk

First you can review that points you have assigned:

m9edifnd>/>A

Full Match vs Partial Match vs Some Words

m9edifind

• The Address component consists of a number portion and a word portion so the points awarded will be double what you assign on this screen. Therefore each (Y)es selection at the bottom indicates the awarded points will be divisible by 2. If all options are set to (Y)es, but only one comparison finds a match, the awarded points will be divisible by 8.

• Next run ‘m9prvlk’ via the programmer’s utility

• Enter claim number• Print to view

• When Normalization and Metaphone are applied, vowels and specified words are removed.

FULL MATCH: No Normalization, full words comparedNM1*85*1*Patton*Melanie*P***XX*1639101751~

Inbound

HEALTHpac

RPC_B1A1 / Provider Last > PRV_LNAME / HP4

Provider Last

RPC_B1A2 / Provider First > PRV_FTNAME / HP4

Provider First

‘PATTON*MELANIE*P’ vs ‘PATTON*MELANIE*P’ - FULL MATCHNote: points will be awarded on Office Name or Provider Name but not both, NM102 Entity Type Qualifier indicates which will be applied. UB only has a ‘2’ option for Entity Type qualifier, so no points should be expected on Provider Name for UB matching.

PARTIAL MATCH: Normalization occurs, normalized strings are compared and the Shortest string from inbound file fits within the larger string in HP4.

• Full Match attempt: ‘PATTAN*MELANIE P’ vs ‘PATTON*MELANIE*P’ - No

• PARTIAL attempt ‘PTTN*MLNP’ vs ‘PTTN*MLN*P’-PARTIAL MATCH on

both• *NOTE: There could be a full match on the last name and only a

partial on the first name

• SOME WORDS MATCH: Normalization occurs and a word matches

• FULL ‘SAINT JOE’S HOSPITAL’ vs ‘ST JOSEPH’S HOSPITAL MEDICALCENTER

- NO

• PARTIAL ‘SNTJSHSPTL’ vs ‘STJSPHSHSPTLMDCLCNTR’ - NO

• SOME ‘SNTJSHSPTL’ vs ‘STJSPHSHSPTLMDCLCNTR’ SOME

WORDS

FLOWCHART

• The points matching program (m9edifnd) will now have (F)ind as an option on the Select bar:

• You will be taken to an entity search screen. Your initial match point settings will be identified as ‘Default’. You can either type ‘Default’ or choose another valid entity ID:

• You will see the appropriate entity ID on the top banner:

• ‘Partial Match Character Req’ will be added:• The default that will be populated in this field is “1”

which will allow the current Partial Match functionality to remain unchanged.

• User will be able to enter 1,2, or 3 in this field which will be read during the Partial Match logic to determine the character requirement for the shortest string.

• The existing partial matching logic consists of comparing the shortest string to the longest string to length of the shortest string this will be modified.

• The new Partial Match Character Req will now determine the required character length of the shortest string.

• If the shortest string once is less than the requirement no points will be assigned for those criteria.

• If the shortest string is equal to or greater than the requirement points can be assigned if passes.

• New NPI logic:• The existing NPI matching logic currently does not

compare any of the client specific matching criteria once a NPI number has been found. Once a provider with a matching NPI is found the system will only use those providers to gather points.

• Provider with the correct point assignment will be selected. *NPI will be stored in the CLAIM F10 screen – RPH_UPINORIG

• If provider cannot be determined based on point assignment the current Provider Not Found exception will occur.

X12 CUSTOMIZATION FLAGS

X 1 2 M E S S AG E C U S T O M I Z AT I O N

Seen me lately? Currently 20 flags exist under this table....

This program incorporates a number of client-requested custom designed options.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #1 = When the flag is set to "Y" HEALTHpac is expecting to receive the image ID in REF*D9 segment. If the flag is set to “N”, HEALTHpac will then expect the image ID in REF*F8 segment.


Flag #2 = When the flag is set to "Y" HEALTHpac is expecting to receive the BLI key from Bases Loaded, for exact provider matching. When the flag is set to “N”, HEALTHpac will then default to standard provider matching process.3.


Flag #3 = Client who requested this option is a ‘repricing only’ organization. This client required the allowed amount to be the Amount To Pay as stated on their Repricing Sheet, rather than the traditional allowed amount which reflects what the PPO allows. For those clients that are not repricing only, the amount to pay would not be the correct allowed amount as it would contain any other adjustments/discount that have been applied based on the benefit plan or logic set up.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #4 = When the flag is set to "Y" HEALTHpac will create an additional REF segment in Loop: 2010BA. When the flag is set to “N”, the REF segment will not extract.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #5 = When the flag is set to "Y" HEALTHpac is expecting a REF*ZZ segment in Loop: 2000 which will contain Beneficiary Name. This info will import in the Employee Master. When the Flag is set to “N”, HEALTHpac will not update the Beneficiary Name field.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #6 = This flag may be turned ON when you have employees who are active in multiple groups. Setting this flag to “Y” HEALTHpac will expect to receive the Underwriter+Group codes in the SBR03 segment. Setting the flag to “N” will follow regular patient match routine, HEALTHpac will select the first group member is found on. For example, member is active in Group: ABC and XYZ….when the file is imported, HEALTHpac will attach the member attached to group: ABC20

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #7 = This flag was created to allow 837 outbound files for Repricing only groups to maintain the Original Claim Number in the REF*D9 Segment.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #8 = This flag was created to allow for only ‘provider not found’ claims to be selected to be sent to Bases Loaded. Inbound files will have the BLI key received from Bases Loaded.

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #9 = This flag was created BC/BS of California to meet requirements set by BC/BS. Any coverage eligibility changes (i.e. level of coverage or status) made while the Blue Cross/Blue Shield flag is set to "Y" HEALTHpac will generate the true effective date for the outbound 834 file on segment DTP*348 (Loop 2300).

X 1 2 M E S S AG E C U S T O M I Z AT I O N Flag #10 = This flag was also created for BC/BS of California. When this flag is set to “Y” then all of the information received from the PWK segment will write to the Claim Notes.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #11 = Post-Adjudication Only - When the flag is set to "Y" will look to the amount on segment HCP17 to correctly distribute the U&C and Discount amounts to their respective fields on the service line. The correct denied reason code linked to the Out-of-Network claim will come from the Default Plan Pricing fields in the benefit plan. When the flag is set to "N" the module will retain the current functionality and not separate U&C and Discount amounts on an Out-of-Network claim.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #12 = When the flag is set to “Y” the system will display the service dates received from the DTP*472 Service Line Date segment (loop: 2400). When the flag is set to ”N” the system will display the service dates from the DTP*434 Statement Date segment (loop: 2300). This flag only applies for Institutional claims.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #13 = When setting this flag to a "Y" a resulting 837 outbound file's SBR*03 Segment will now contain a value in the format of "GRP=######" to represent the claim's Underwriter & Group.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #14 = When the flag is set to “Y” the system will select the DTP*431 Onset of Current Illness/Symptom segment (loop: 2300) for the INCURRED date field. When the flag is set to “N” the system will select the earliest DTP*472 Service Date segment (loop: 2400) for the INCURRED date field.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #15 = Post-Adjudication Only - When the '837 outbound (Post-Adj): Include extended information' flag is set to "Y" the following amounts will write to the K3 segment (Loop 2400) for Professional files and the CAS segment (Loop 2430) for Institutional files: Deductible, Co-pay, Co-insurance, Discount, Allowable and/or Over U&C amounts. When the flag is set to "N" the additional information will not write, only the Ineligible amounts will continue to extract to the file.

For example: CAS*OA*2*.90*2*3*3.00*02*4*6.01*1B*5*23.99*5~

(Co-ins) (Co-pay) (Discount) (Allowable)

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #16 = Currently in HEALTHpac the system generates an effective date and termination date for the benefit plan, products (i.e. medical, dental) members and dependents. This is formatted in an 834 outbound file that will include eligibility levels and multiple HD segments (Health Coverage Loop 2300) per HIPAA guidelines. When the flag is set to a “Y” if the level of coverage changes and benefits plans are the same, HEALTHpac will not create the DTP*349 (Benefit Ends) segment and will pass only one HD segment (Health Coverage) in Loop 2300.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #17 = Currently when setting flag to “Y” HEALTHpac will obtain the allowed amount from the HCP segment(s). Setting flag to “N” the system will obtain the allowed amount using a calculated formula. Please refer to the ‘5010 – COB Formula’ Handout for further details.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #18 = Post-Adjudication Only – A new post-adjudication flag added to the X12 Message Customization screen; 837 inbound (Post-Adj): Avoid logic if only applying edit. When the flag is set to "Y" the claim will not re-read adjudication logic or the control rules in the benefit plan. When the flag is set to "N" the post-adjudication process will function as normal and re-read any logic.

X 1 2 M E S S AG E C U S T O M I Z AT I O NFlag #19 = Post-Adjudication Only – When the “User in 'Status of Claim' field remains is set to "Y", the system will not update the date/user unless that user entered the claim and made changes to the claim. When the flag is set to “N” the system will function as normal and update the field by last user who affected the claim – even importing/exporting files. The Audit History will continue to document the true user, date and time.

X 1 2 M E S S AG E C U S T O M I Z AT I O NNEW - Flag #20 = Post-Adjudication Only – Allow adjustment related claims to create 837 files. If set to ‘Y’ adjustment claims will be sent in the post-adjudication extract. If set to ‘N’, adjustment claims will not be sent.

-NEW NM1*77 CUSTOMIZATION FLAG-UNDERSTANDING OUTBOUND PROVIDER LOOPS WITH PAYMENT ADDRESS ENHANCEMENT

• Currently if a ‘Payment Address’ exists on a provider

record, in an outbound 837 the system will place the

‘Payment Address’ information in the NM1*85

(Billing Provider loop). It will then place the Provider

Master address information in the NM1*77 (Service

Provider loop).

• The problem is, this is not HIPAA compliant. It’s

possible that the Payment Address may not be a

physical address(i.e. PO Box).

• The ‘Payment Address’ will go into the NM1*87 (Pay-

To Provider loop).

• Slated for 4.11.01 there will be an enhancement to create a new customization flag – ‘837 OUT-Sup Serv Fac/NM177’. The default for this flag will be ‘Y’. This means that if the provider record address matches the ‘Payment Address’ the NM1*77 will be suppressed. If set to ‘N’ an NM1*77 will be created regardless.

• Wanted to give clients the option of keeping the NM1*77

• SUMMARY

• With the customization flag set to ‘Y’(to suppress NM1*77 when it matches the billing address), the only time an NM1*77 would exist in an outbound file is when the claim came in via EDI and had a separate NM1*77 address.

• The ‘Payment Address’ will now be sent out in the NM1*87(Pay-To provider loop) appropriately.

-NEW X12 FLAGS TO CONTROL K3/NTE NOTES

• Four new flags will be added to the Customization screen scheduled for 4.11.01. These will give the client the option to write the K3 or NTE segments to the claim notes down to the claim/service line level from an inbound 837.

• Sample Notes and how they display in claim notes based on where they come from

• If the NTE segments exist in loop 2300, the claim notes will be preceded with NTE-CLM:

• If the NTE segments exist in loop 2400, the claim

notes will be preceded with NTE-SVC1:, NTE-SVC2,

etc.

• If the K3 segments exist in loop 2300, the claim

notes will be preceded with K3-CLM:

• If the K3 segments exist in loop 2400, the claim notes will be preceded with K3-SVC1:, K3-SVC2, etc..

W H E R E C A N I G O T O G E T M O R E I N F O R M AT I O N ?

http://www.cms.gov/Versions5010andD0

http://www.emdeon.com/5010

http://www.wpc-edi.com

Any Questions?

[email protected]@eldocomp.comSupport Line: 602-604-3100

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EDI PRESENTED BY: MATT DOBRY, ELDORADO CHARLEEN MULLANEY, HEALTH PLANS INC. AND JEREMY FELDBRUEGGE,...

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Transcript of EDI PRESENTED BY: MATT DOBRY, ELDORADO CHARLEEN MULLANEY, HEALTH PLANS INC. AND JEREMY FELDBRUEGGE,...