Cardinal Innovations Healthcare...documents without the written permission of the copyright holder....

Cardinal Innovations Companion Guide

Health Care Claim: Institutional (837I) ASC X12 005010X223A2

March 2018 ● 005010 1

Cardinal Innovations Healthcare

837I Companion Guide

Instructions Related to Transactions Based on ASC X12 Implementation Guide

Version 005010X223A2 Health Care Claim: 837 Institutional

Companion Guide Version Number: 3.1 March 28, 2018



March 2018 ● 005010 2

This template is copyrighted © 2010 by The Workgroup for Electronic Data Interchange (WEDI) and the Data Interchange Standards Association (DISA), on behalf of the Accredited Standards Committee (ASC) X12. All rights reserved. It may be freely redistributed in its entirety provided that this copyright notice is not removed. It may not be sold for profit or used in commercial documents without the written permission of the copyright holder. This document is provided “as is” without any express or implied warranty. Note that the copyright on the underlying ASC X12 Standards is held by DISA on behalf of ASC X12. 2018 © Companion Guide copyrighted by Cardinal Innovations



March 2018 ● 005010 3

Preface Companion Guides (CG) may contain two types of data, instructions for electronic

communications with the publishing entity (Communications/Connectivity Instructions) and

supplemental information for creating transactions for the publishing entity while ensuring

compliance with the associated ASC X12 IG (Transaction Instructions). Either the

Communications/Connectivity component or the Transaction Instruction component must be

included in every CG. The components may be published as separate documents or as a single

document.

The Communications/Connectivity component is included in the CG when the publishing entity

wants to convey the information needed to commence and maintain communication exchange.

The Transaction Instruction component is included in the CG when the publishing entity wants

to clarify the IG instructions for submission of specific electronic transactions. The Transaction

Instruction component content is limited by ASCX12’s copyrights and Fair Use statement.



March 2018 ● 005010 4

Table of Contents

1 TI Introduction .......................................................................................................... 5

1.1 Background ................................................................................................................... 5

1.1.1 Overview of HIPAA Legislation ........................................................................... 5

1.1.2 Compliance according to HIPAA ......................................................................... 5

1.1.3 Compliance according to ASC X12 ..................................................................... 6

1.2 Intended Use ................................................................................................................. 6

1.3 Intended Audience ........................................................................................................ 6

1.4 Purpose of Companion Guide ....................................................................................... 6

1.5 Trading Partner Agreement ........................................................................................... 6

1.6 Resources ..................................................................................................................... 6

1.7 Version Updates............................................................................................................ 6

2 Included ASC X12 Implementation Guides ............................................................ 7

3 Instruction Tables .................................................................................................... 8

4 TI Change Summary .............................................................................................. 15



March 2018 ● 005010 5

Transaction Instruction (TI)

1 TI Introduction

1.1 Background

1.1.1 Overview of HIPAA Legislation

The Health Insurance Portability and Accountability Act (HIPAA) of 1996

carries provisions for administrative simplification. This requires the

Secretary of the Department of Health and Human Services (HHS) to adopt

standards to support the electronic exchange of administrative and financial

health care transactions primarily between health care providers and plans.

HIPAA directs the Secretary to adopt standards for transactions to enable

health information to be exchanged electronically and to adopt specifications

for implementing each standard HIPAA serves to:

Create better access to health insurance

Limit fraud and abuse

Reduce administrative costs

1.1.2 Compliance according to HIPAA

The HIPAA regulations at 45 CFR 162.915 require that covered entities not

enter into a trading partner agreement that would do any of the following:

Change the definition, data condition, or use of a data element or segment in a

standard.

Add any data elements or segments to the maximum defined data set.

Use any code or data elements that are marked “not used” in the standard’s

implementation specifications or are not in the standard’s implementation

specification(s).

Change the meaning or intent of the standard’s implementation specification(s).

1.1.3 Compliance according to ASC X12

ASC X12 requirements include specific restrictions that prohibit trading

partners from:

Modifying any defining, explanatory, or clarifying content contained in the

implementation guide.

Modifying any requirement contained in the implementation guide.



March 2018 ● 005010 6

1.2 Intended Use

The Transaction Instruction component of this companion guide must be used in

conjunction with an associated ASC X12 Implementation Guide. The instructions

in this companion guide are not intended to be stand-alone requirements

documents. This companion guide conforms to all the requirements of any

associated ASC X12 Implementation Guides and is in conformance with ASC

X12’s Fair Use and Copyright statements.

1.3 Intended Audience

This companion guide is intended for business and technical users responsible for

the testing and setup of electronic claims submissions between Trading Partners

and Cardinal Innovations Network.

1.4 Purpose of Companion Guide

The Companion Guide is to be used with, and to supplement, the requirements in

the HIPAA ASC X12 Implementation Guides, without contradicting those

requirements. The HIPAA ASC X12 Implementation Guides Implementation

Guides define the national data standards, electronic format, and values for each

data element within an electronic transaction. The purpose of the Companion

guide is to provide Trading Partners with a guide to communicate specific Cardinal

Innovations Network information required to successfully exchange transactions.

1.5 Trading Partner Agreement

Providers or vendors who directly transmit electronic claims to Cardinal

Innovations must complete a Cardinal Innovations Trading Partner Agreement

(TPA).

1.6 Resources

The following resources were used in preparing this Companion Guide.

Washington Publishing Company www.wpc-edi.com

ASC X12 www.X12.org

NCTracks www.nctracks.nc.gov

1.7 Version Updates

This Companion Guide will be updated as needed based on changes to Federal

guidelines and Cardinal Innovation Healthcare’s claim adjudication requirements.

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

http://www.x12.org/

http://www.nctracks.nc.gov/



March 2018 ● 005010 7

Included ASC X12 Implementation Guides

This table lists the X12N Implementation Guides for which specific transaction

Instructions apply and which are included in Section 3 of this document.

Unique ID Name 005010X223 Health Care Claim: Professional (837I) 005010X223A1 Health Care Claim: Professional (837I) 005010X223A2 Health Care Claim: Professional (837I)



March 2018 ● 005010 8

2 Instruction Tables

These tables contain one or more rows for each segment for which a supplemental

instruction is needed.

Legend

SHADED rows represent “loops and segments” in the X12N implementation guide.

NON-SHADED rows represent “data elements” in the X12N implementation guide.

005010X222A1 Health Care Claim: Professional

Loop ID Reference Name Codes Notes/Comments

Header ISA Interchange

Control Header

ISA03 Interchange Control Security Information

Qualifier

00 Use “00” – No Security Information

Present.

ISA05 Interchange ID

(Sender) Qualifier ZZ Use “ZZ” – Mutually

Defined.

ISA06 Interchange

Sender ID

Use the Submitter ID issued to you by Cardinal Innovations. Same as

GS02.

ISA07 Interchange ID

(Receiver) ID

ZZ Use “ZZ” – Mutually

Defined.

ISA08 Interchange

Receiver ID

Use “06607”. Same as GS03.

Header GS Functional Group

Header

GS02 Application

Sender’s Code Use the Submitter ID

issued to you by Cardinal

Innovations. Same as

ISA06.

GS03 Application

Receiver’s Code Use “06607”. Same as

ISA08.

Header ST Transaction Set Header

ST03 Implementation Conversion Reference

005010X223

A2

Refer to section 1.2 of

Implementation Guide

1000A NM1 Submitter Name

NM108 Identification Code Qualifier

46 Use “46” - Electronic Transmitter ID Number

NM109 Identification Use the Submitter ID



March 2018 ● 005010 9


Code issued to you by Cardinal Innovations. Same as ISA

ISA06 and GS02.

1000B NM1 Receiver Name

NM103 Receiver Name Use “Cardinal Innovations”


46 Use “46” - Electronic Transmitter ID Number

NM109 Receiver Primary Identifier

Use “06607”. Same as ISA ISA08 and GS03.

2000A Billing Provider Hierarchy Level

The Billing Provider Information is critical to successfully adjudicating a

provider claim. The Billing Provider’s NPI number, taxonomy code and nine-digit zip code must be enrolled at NCTracks in a current and active provider record with a service

location code of ‘03’ or greater. Billing Provider entries must also follow the NPI enumeration rules detailed

in the X12 837I TR3 (Federal implementation guide). If a Provider site

has its own unique NPI number, then that site must be listed as the Billing Provider in the

837I.

2000A PRV Billing Provider Specialty

Required by Cardinal Innovations. Enter the taxonomy code in the Billing Provider Loop.

PRV01 Provider Code BI Use “BI” – Billing Provider

PRV02 Identification Code Qualifier

PXC Use “PXC” – Taxonomy Code

PRV03 Taxonomy Code Use the Billing Provider’s

Taxonomy Code. This

taxonomy code must be listed in an active NCTracks provider record that also contains the NPI used in 2010AA, NM109 and the nine digit zip code used in Loop 2010AA,

N403.

2010AA NM1 Billing Provider Name

NM108 Billing Provider ID XX Use “XX” = NPI number



March 2018 ● 005010 10


Qualifier

NM109 Billing Provider ID Use the Billing Provider’s NPI number. This NPI number must be listed in an active NCTracks provider record that also contains the Taxonomy code used in 2000A,

PRV03 and the nine digit zip code used in Loop 2010AA, N403.

2010AA NM4 Billing Provider City, State, Zip Code

N403 Billing Provider Nine-Digit Zip Code

Use the Billing Provider’s nine-digit zip code. This nine-digit zip code must be listed in an active NCTracks provider record that also contains the NPI

used in 2010AA, NM109 and the Taxonomy code used in 2000A, PRV03.

2010AC Pay-to-Plan Cardinal Innovations will

not use this loop

2000B SBR Subscriber Information

SBR09 Claim Filing

Indicator Code MC, ZZ Use “MC” for Medicaid

claims Use “ZZ” – State Funds

claims

2010BA NM1 Subscriber Name


MI Use “MI” - Member Identification Number

NM109 Subscriber Primary Identifier

For Medicaid, use the Member’s 10 digit Medicaid ID ending in an alpha character. For State Funds, use the Member’s ID number

assigned by the MCO.

2010BB NM1 Payer Name

NM103 Payer Name Use “Cardinal Innovations”

NM108 Payer ID Qualifier PI Use “PI” – Payer ID

NM109 Payer Identifier Use “06607”. Same as ISA

ISA08 and GS03.

2300 CLM Claim Information

CLM05-3 Claim Frequency Code 1,2,3,4,7,8 It is very important to use the correct frequency code, patient status code,



March 2018 ● 005010 11


covered days and statement span in order to

determine whether the last day of the episode is billable. These fields must be in sync. 1 = Full episode claim, discharged 2 = First claim, not

discharged 3 = Interim claim, not discharged 4 = Discharge claim 7 = Replacement claim

8 = Void claim

2300 DTP Discharge Time

DTP01 Discharge Time Code O96 096 = Discharge Date

DTP02 Date Time Qualifier TM TM = Time

DTP03 Discharge Time HHMM format

2300 DTP Statement Date Range

DTP01 Statement Date Code 434 434 = Statement Date

DTP02 Date Time Qualifier RD8 RD8 = Date Range

DTP03 Statement Date Range CCYYMMDD - CCYYMMDD

2300 DTP Admission Date

DTP01 Admission Date Code 435 435 = Admission Date

DTP02 Date Time Qualifier D8, DT D8 = CCYYMMDD

DT = CCYYMMDDHHMM

DTP03 Admission Date Time CCYYMMDD format or CCYYMMDDHHMM

Note: The discharge time,

statement dates and admission date must be in sync with the claim frequency code, the patient status code and the covered days.

2300 CL1 Institutional Claim Codes

CL103 Patient Status Code Must use

codes from

the NUBC

code list

The patient status code must clearly indicate whether the patient has

been discharged or is still a patient. The code must be in sync with the claim frequency code, the statement dates and the covered days.

2300 REF Payer Claim Control Number



March 2018 ● 005010 12


REF01 Reference Identification Qualifier

F8 Use “F8” - Original Reference Number - when

CLM05-3 is equal to 7 or 8

REF02 Reference Identification

Use Cardinal Innovation’s ICN associated with the original claim that is being replaced or voided

2300 HI Value Code – Patient Monthly Liability

HI01 Health Care Code Information

Use to report Patient Monthly Liability (PML) contributions for ICF/IDD

patients.

HI01-1 Qualifier Code BE Use “BE” - Value

HI01-2 Value Code 23 Use “23” – Patient Share of Cost

HI01-5 Value Amount Dollar amount of PML

contribution. This should only be reported on the first claim of the month or until the SSI is depleted for the month.

2300 HI Condition Code – Covered Days

HI01 Health Care Code Information

Use to report the number of covered days for an inpatient stay.

HI01-1 Qualifier Code BE Use “BE” - Value

HI01-2 Value Code 80 Use “80” – Covered Days

HI01-5 Value Amount The number of inpatient days for which the provider expects Cardinal

Innovations Healthcare to pay. The covered days must be in sync with the claim frequency code, the statement dates and the patient status code.

2310E Service Facility Location Information

The Service Facility Location is the site where

the service was delivered. Required by Cardinal Innovations if the Service

Facility Location Information is different than the Billing Provider Information in Loop 2010AA. Service Facility Location

entries must also follow



March 2018 ● 005010 13


the NPI enumeration rules detailed in the X12 837I

TR3 (Federal implementation guide). If a Provider Site/Service Facility Location has its own unique NPI number, then that Site/Service Facility Location must be

listed as the Billing Provider in the 837I. The NPI information in Loop 2310E is situational,

meaning that the service might have been delivered

at a site that does not have an NPI number. Also, the site might be a Billing Provider site that was not enumerated, meaning that the site does not have a

unique NPI. In these cases, the 2310E, NM108 and NM109 will not be used. The address and nine-digit zip code are still required.

2310E NM1 Service Facility

Location Name

NM108 Service Facility Location ID Qualifier

XX 2310E NM108 is a situational field. Use “XX” = NPI number, if the

Service Facility Location has an NPI number.

NM109 Service Facility Location ID

2310E NM109 is a situational field. Use the Service Facility Location’s NPI number if the Service

Facility Location has a unique NPI number. This NPI number must be listed in an active NCTracks provider record

that also contain the nine-digit zip code used in Loop

2310E N403.

2310E N4 Service Facility Location City, State, Zip

N403 Service Facility Location Nine-Digit Zip Code

If the Service Facility Location NPI field is used, then the Service Facility Location nine-digit zip code and NPI must be



March 2018 ● 005010 14


listed in an active NCTracks provider record.

If the Service Facility Location NPI is not used, then the nine-digit Service Facility Location zip code must be linked to the Billing Provider NPI and

Taxonomy code in Loop 2010AA.

2320 Other Subscriber Information

2320 AMT Coordination of

Benefits Other Payer Paid Amount

AMT01 Amount Qualifier Code D Cardinal Innovations only uses “D” – Payer Amount Paid

AMT02 Other Payer Paid Amount

2410 LIN Drug identification Loop 2410 is required when a drug is administered by a provider during an emergency room

visit and a drug related HCPCS code is reported in SV202-2. Cardinal Innovations only pays for

drugs for Medicaid Members administered during an emergency room

visit, or administered during Hospital Outpatient procedures. Prescriptions and self-administered drugs are not covered.

2410 REF Prescription or

Compound Drug Association Number

REF01 Reference Identification Qualifier

VY Use “VY” - Link Sequence Number



March 2018 ● 005010 15

3 TI Change Summary Version 1.0 January 1, 2014 Cardinal Innovations

Version 2.0 February 1, 2018 Cardinal Innovations

Version 3.0 March 21, 2018 Cardinal Innovations

Version 3.1 March 28, 2018 Cardinal Innovations

Cardinal Innovations Healthcare...documents without the written permission of the copyright holder....

Documents

Transcript of Cardinal Innovations Healthcare...documents without the written permission of the copyright holder....