UCare 835 Companion Guide · 1/1/2019 · This Companion Guide is intended to describe to UCare...

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HIPAA Transaction Standard Companion Guide 835 (ERA) Electronic Remittance Advice

Health Care Claim Payment/Advice

VERSION: 1 DATE: 01/01/2019

UCare Minnesota v5010 ASC X12N (ASC X12N 005010X221A1) 835 Companion Guide


Disclosure Statement This document is intended to be a companion guide for use in conjunction with the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides. This document contains clarifications as permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Standard for Electronic Transactions. This document is not intended to convey information that exceeds the requirements or usages of data expressed in the ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides defined by HIPAA. UCare is committed to maintaining the integrity and security of health care data in accordance with applicable laws and regulations. This material contains confidential, propriety information. Unauthorized use or disclosure of the information is strictly prohibited. The information in the document is furnished for UCare and Trading Partner use only. Changes are periodically made to the information in this document, these changes in the product and/or program described in the publication at any time. Disclosure of beneficiary data is restricted under the provisions of the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Provider Beneficiary transaction is to be used for conducting UCare business only. Please note: Payment of benefits remains subject to all health benefit plan terms, limits, conditions, exclusions and the member’s eligibility at the time services are rendered.



Table of Contents

Disclosure Statement 2

Table of Contents 3

Introduction

Scope 4

References 4

Additional References 4

Getting Started

Working with UCare 5

835 Electronic Remittances Advice Specifications

Information about the Health Care Claim Payment Advice (835) Transaction 6

Data Content and Specifications 7-11

General Notes 12

Contact Information 12

Trading Partner Agreements 12

Appendices 13



Introduction This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies

and specifies the data content when exchanging electronically with UCare. Transmissions based on this companion guide,

used in conjunction with the v5010 ASC X12N Implementation Guides and the Minnesota Uniform Companion Guides, are

compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is

within the framework of the ASC X12N Implementation Guides and Minnesota Uniform Companion Guides adopted for use

under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or

usages of data expressed in the Implementation Guides.

Scope This Companion Guide is intended to describe to UCare trading partners the content for the ASC/X12N 835 5010 transaction with UCare. This Companion guide is designed to assist those who receive Electronic Remittance Advice (ERA) and/or payments in the 835 format from UCare. This guide is intended to supplement information from the ASC X12 Technical Reports Type 3 (TR3s).

References ASC X12 publishes implementation guides, known as Technical Reports Type 3 (TR3s), which define the data contents and

compliance requirements for the health care implementation of the ASC X12N/005010 transaction sets. Following are the

Interchange Technical Report Type 3 (TR3s) referenced in this guide:

ASC X12N/005010X221A1 Health Care Payment/Advice (835) and

Associated errata, hereinafter 005010X221A1 TR3s.

You are expected to comply with the requirements set forth in the TR3s. You can purchase these guides from the ASC X12

store at http://store.x12.org/ or from Washington Publishing Company (http://www.wpc-edi.com).

Entities subject to Minnesota Statutes, section 62J.536 and related rules must follow the data content and other transaction-

specific information of the Minnesota Uniform Companion Guide for the Implementation of the ASC X12/005010X221A1

Health Care Payment/Advice (835). A copy of the Minnesota Uniform Companion Guide is available at no charge from the

Minnesota Department of Health at: http://www.health.state.mn.us/asa/rules.html

Additional Information This transaction supports Electronic Remittance Advice (ERA) and/or payments in the 835 format for UCare. This Companion

Guide assumes that you, the reader, are a representative of the Trading Partner or Provider, and that as such, you

understand basic X12 structure, looping, and standard data requirements as set forth in the TR3 for each transaction set you

wish to exchange.

This Companion Guide also assumes that:

You have an EDI interface that supports the transaction sets the Trading Partner wishes to exchange.

You have resources to develop a connection between your interface and choice of trading partner.

http://store.x12.org/

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

http://www.health.state.mn.us/asa/rules.html



Getting Started

Trading Partner Registration Before receiving an 835 transaction NOTE: You must register with a clearinghouse to receive 835s before UCare can send 835s to your clearinghouse and before you complete and submit the form below.

UCare’s payer ID: 52629 and 55413 Below is the EFT and ERA Authorization Agreement form link: https://www.ucare.org/providers/Claims-Billing/Pages/EFTERAElectionForm.aspx Please allow a minimum of 30 days for processing. You will be notified in advance of the date when the electronic RAs and/or EFT process will begin.

CONTACT INFO:

For additional application questions:

Phone: 1-612-884-2030

Email: [email protected]

Days/Times: Monday - Friday, 8:00 a.m. – 5:00 p.m. CST

Clearing House Registration UCare Agreement

https://www.ucare.org/providers/Claims-Billing/Pages/EFTERAElectionForm.aspx

mailto:[email protected]



Information about the Health Care Claim Payment Advice (835) Transaction

Adjustment As defined in the 005010X221A1 TR3, “the term adjustment refers to changes to the amount paid on a claim, service or remittance advice versus the original submitted charge/bill. Adjustment does not refer to changing or correcting a previous adjudication of a claim.” CARC and RARC Updates/Changes National organizations are responsible for maintenance of CARC and RARC and periodically add, delete, or make other changes to these codes. This Guide and Appendix incorporate by reference any changes adopted by national organizations with responsibilities for these codes. CARC are updated (additions, deletions, changes) three times/year by the Joint Claim Adjustment Reason/Health Care Claim Status Reason Code Maintenance Committee. These updates are published by Washington Publishing Company at www.wpc-edi.com. RARC are maintained by the federal Centers for Medicare & Medicaid Services (CMS). Updates to the Remark Codes (additions, changes, deletions) are published by Washington Publishing Company at www.wpc-edi.com. Relationship and Importance of Accurate Balanced 835 Transaction for 837 Coordination of Benefits COB It is necessary that the 835 transactions balance, contain accurate information, and utilize active CARC, RARC or NCPDP reject codes. After the receipt and posting of the 835 payment and/or adjustment data, this data must be used in 837 Coordination of Benefits (COB) situations. When submitting COB claims to secondary/tertiary payers, the provider needs to populate the appropriate 837 segments with the prior payer’s payment and/or adjustment data. If this data is inaccurate, or does not balance, then the subsequent 835 payment and remittance advice from the secondary/tertiary payer may be delayed, or inaccurate.





Loop Segm

en

t/

Elem

ent

Description

Elem

ent

Len

gth

Mapping Comments

Interchange Control Header Required

ISA Interchange Control Header To start and identify an interchange of zero or more functional groups and interchange-related control segments

ISA01 Authorization Information Qualifier 2/2 Code identifying the type of information in the Authorization Information

ISA02 Authorization Information 10/10 Information used for additional identification/authorization of the interchange sender or the data in the interchange.

ISA03 Security Information Qualifier 2/2 Code identifying the type of information in the Security Information

ISA04 Security Information 10/10 Security Information about the interchange sender or the data in the interchange.

ISA05 Interchange Sender ID Qualifier 2/2 Code indicating the system/method of code structure used to designate the sender or reliever ID element being qualified

ISA06 Interchange Sender ID 15/15

Identification code published by the sender for other parties to use as the receiver ID to route data to them; the sender always codes this value in the sender ID element

ISA07 Interchange Receiver ID Qualifier 2/2 Code indicating the system/method of code structure used to designate the sender or reliever ID element being qualified

ISA08 Interchange Receiver ID 15/15 Identification code published by the receiver of the data; When sending, it is used by the sender as their sending ID, thus other parties sending to them will use this as a receiving ID to route data to them

ISA09 Interchange Date 6/6 Date Expressed in YYMMDD format

ISA10 Interchange Time 4/4 Time in HHMM format

ISA11 Repetition Separator 1/1 The repetition separator is a delimiter and not a data element: the field provides the delimiter used to separate repeated occurrences of a simple data element or a composite data structure

ISA12 Interchange Control Version Number 5/5 “00501” Standards Approved for Publication by ASC X12 Procedures Review board

ISA13 Interchange Control Number 9/9 A control number assigned by the interchange sender The Interchange Control Number, ISA13, must be identical to the associated Interchange Trailer IEA02.

ISA14 Acknowledgement Request 1/1 Code indicating sender’s request for an interchange acknowledgement.

ISA15 Usage Indicator 1/1 Code indicating whether data enclosed by this interchange envelope is a test, production or information.

ISA16 Component Element Separator 1/1 Type is not applicable; the component element separator is a delimiter and not a data element; this field provides the delimiter used to separate component data elements within a composite data structure; this value must be different than the data element separator and the segment terminator

Functional Group Header Required

GS Functional Group Header To indicate the beginning of a functional group and to provide control information

GS01 Functional Identifier Code 2/2 “HP” Health Care Claim Payment/Advice code (835)

GS02 Application Sender’s Code 2/15 Code identifying party sending transmission; codes agreed to by trading partners

GS03 Application Receiver’s ID 2/15 Code identifying party receiving transmission; codes agreed to by trading partners

GS04 Date 8/8 Date Expressed in CCYYMMDD format



GS05 Time 4/8 Time Expressed in HHMMSS format

GS06 Group Control Number 1/9 Assigned number originated and maintained by the sender. The data interchange control number GS06 in this header must be identical to the same data element in the associated functional group trailer, GE02

GS07 Responsible Agency Code 1/2 Code identifying the issuer of the standard

GS08 Version/Release/Industry Identifier 1/12 “005010X221A1” Standards Approved for Publication by ASC X12 Procedures Review Board

Transaction Set Header Required

ST Transaction Set Header To indicate the start of a transaction set and to assign a control number

ST01 Transaction Set Identifier Code 3/3 “835” Health Care Claim Payment/Advice

ST02 Transaction Set Control Number 4/9 Identifying control number that must be unique within the transaction set functional group assigned by the originator for a transaction set. Transaction Set Control Number- Must equal SE02

BPR Financial Information Required

BPR01 Transaction Handling Code 1/2 Code designating the action to be taken by all parties. Example: “I” Remittance Information Only (The remittance detail is moving separately from the payment)

BPR02 Monetary Amount 1/18 Total Actual Provider Payment Amount

BPR03 Credit/Debit Flag Code 1/1 Example: “C” Credit “D” Debit

BPR04 Payment Method Code 3/3 Example: “CHK” Check “ACH” Electronic EFT Payment

BPR05 Payment Format Code 1/10 Example: “CCP” Cash Concentration/Distribution plus addenda (CCCD+)-(ACH)

BPR06 (DFI) ID Number Qualifier 2/2 Code identifying the type of identification number of Depository Financial Institution (DFI) Example: “01” ABA Transit Routing Number

BPR07 (DFI) Identification Number 3/12 Sender DFI Identifier

BPR08 Account Number Qualifier 1/3 Code indicating the type of account. Example: “DA” Demand Deposit

BPR09 Account Number 1/35 Sender Bank Account Number

BPR010 Originating Company Identifier 10/10 Payer Identifier

BPR11 Originating Company Supplement Code 9/9 Originating Company Supplement Code

BPR12 (DFI) ID Number Qualifier 2/2 Code identifying the type of identification number of Depository Financial Institution (DFI) Example: “01” ABA Transit Routing Number

BPR013 (DFI) ID Number 3/12 Receiver or Provider Bank ID Number

BPR014 Account Number Qualifier 1/3 Code indicating the type of account. Example: “DA” Demand Deposit

BPR015 Account Number 1/35 Receiver or Provider Account Number

BPR016 Date 8/8 Date Expressed in CCYYMMDD format. Check or EFT Effective Date

TRN Reassociation Trace Number Required

TRN01 Trace Type Code 1/2 Code identifying which transaction is being referenced. Example: “1” Current Transaction Trace Numbers

TRN02 Reference Identification 1/50 Check or EFT Trace Number

TRN03 Originating Company Identifier 10/10 Payer Identifier

TRN04 Reference Identification 1/50 Originating Company Supplemental Code

DTM Production Date Situational

DTM01 Date Time Qualifier 3/3 Code specifying type of date/time. Example: “405” Production

DTM02 Date 8/8 Date Expressed in CCYYMMDD format.

1000A Payer Identification Required

N1 Payer Identification To identify a party by type of organization, name, and code

N101 Payer Identifier Code 2/3 Code identifying an organizational entity, a physical location, property or an individual. Example: “PR” Payer



N102 Payer Name 1/60 Name of organizational entity, a physical location, property or an individual Example: “UCare”

N3 Payer Address Required

N301 Payer Address Line 1/55 Payer Address Information. Example: “P.O. Box 52”

N4 Payer City, State, Zip Code Required

N401 Payer City Name 2/30 Payer City Name. Example: “Minneapolis”

N402 Payer State Code 2/2 Payer State Code. Example: “MN”

N403 Payer Postal Zone or Zip Code 3/15 Payer Postal Zone/Zip Code. Example: “55440”

PER Payer Technical Contact Information Required

PER01 Contact Function Code 2/2 Code identifying the person/group named. Example: “BL” Technical Department

PER02 Payer Technical Contact Name 1/60 Payer Technical Contact Name. Example: “Provider Assistance Center”

PER03 Communication Number Qualifier 2/2 Code identifying the type of communication. Example: “TE” Telephone

PER04 Payer Contact Communication Number 1/256 Complete communication number. Example: “8885311493”

1000B Payee Identification Required

N1 Payee Identification To identify a party by type of organization, name, and code

N101 Payee/Entity Identifier Code 2/3 Code identifying an organizational, physical location, property or an individual. Example; “PE” Payee

N102 Payee Name 1/60 Payee Name

N103 Payee Identification Code Qualifier 1/2 Code designating the system/method of code structure for Identification Code. Example: “FI” Federal Taxpayer’s Identification Number

N104 Payee Identification Code 2/80 Code identifying a party or other code

N3 Payee Address Situational

N301 Payee Address Line 1/55 Payee Address Information

N302 Payee Address Line 1/55 Payee Address Information

N4 Payee City, State, Zip Code Situational

N401 Payee City Name 2/30 Payee City Name

N402 Payee State Code 2/2 Payee State Code

N403 Payee Postal Zone or Zip Code 3/15 Payee Postal Zone/Zip Code

REF Payee Additional Identification Situational

REF01 Additional Payee Identification Qualifier 2/3 Code qualifying the Reference Identification. Example; “PQ” Payee Identification “TJ” Federal Taxpayers Identification Number

REF02 Reference Identification Code 1/50 Additional Payee Identifier

2000 Header Number Situational (Required when claim or service level information follows)

LX Header Number To reference a line number in a transaction set

LX01 Assigned Number 1/6 Number assigned for differentiation within a transaction set

2100 Claim Payment Information Required

CLP Claim Payment Information To supply information common to all services of a claim

CLP01 Claim Submitter’s Identifier 1/38 Identifier used to track a claim from creation by the health care provider through payment. Patient Control Number

CLP02 Claim Status Code 1/2 Code identifying the status of the entire claim. Examples: 1-Processed as Primary 2-Processed as Secondary 3-Processed as Tertiary 4-Denied

CLP03 Monetary Amount 1/18 The amount of submitted charges this claim

CLP04 Monetary Amount 1/18 The amount paid this claim.

CLP05 Monetary Amount 1/18 The patient responsibility amount

CLP06 Claim Filing Indicator Code 1/2 Code identifying type of claim. Example: “HM” Health Maintenance Organization

CLP07 Reference Identification 1/50 Payer Claim Control Number

CLP11 Diagnosis Related Group (DRG) Code 1/4 Code indicating a patient's diagnosis group based on a patient's illness, diseases, and medical problems

CLP12 Quantity 1/15 Diagnosis-related group (DRG) weight

CLP13 Percent as Decimal 1/10 Discharge Fraction



CAS Claim Adjustment Information Situational (Required when dollar amounts and/or quantities are being adjusted at a claim level.)

CAS01 Claim Adjustment Group Code 1/2 “CO” Contractual Obligation “OA” Other Adjustment “PI” Payer Initiated Reductions “PR” Patient Responsibility

CAS02 Adjustment Reason Code 1/5 Claim Adjustment Reason Code

CAS03 Monetary Amount 1/18 Service Level Adjustment Amount; negative number increases amount, positive decreases

CAS04 Quantity 1/15 Numeric value of adjustment quantity

NM1 Patient Name Required

NM101 Patient Identifier Code 2/3 Code identifying an organizational entity, physical location, property or an individual. Example: “QC” Patient

NM102 Entity Type Qualifier 1/1 Code qualifying the type of entity. Example: “1” Person

NM103 Patient Last Name 1/60 Individual last name or organizational name

NM104 Patient First Name 1/35 Individual first name

NM105 Patient Middle Name 1/25 Individual middle name or initial

NM106 Name Prefix 1/10 Name Prefix

NM107 Name Suffix 1/10 Suffix to individual name

NM108 Identification Code Qualifier 1/2 Code designating the system/method of code structure for identification code. Example: “MI” Member Identification Number

NM109 Identification Code 2/80 Code identifying a party or other code.

REF Other Claim Related Identification Situational

REF01 Reference Identification Qualifier 2/3 Code qualifying the reference identification. Example: “1W” Member Identification Number

REF02 Reference Identification 1/50 Other Claim Related Identification

REF03 Other Claim Related Identification 1/80 Description

2110 Service Payment Information Situational

SVC Service Payment Information To supply payment and control information to a provider for a particular service

SVC01-1 Service Type Code 2/2 AD-American Dental Ass. Codes

ER-Jurisdiction Specific Procedure and Supply Codes

HC-Health Care Financing Administration Common Procedural Coding System (HCPC) Codes

HP-Health Insurance Prospective Payment System (HIPPS) Skilled Nursing Facility Rate Code

IV-Home Infusion EDI Coalition (HIEC) Product/Service Code

N4-National Drug Code in 5-4-2 Format

N6-National Health Related Item Code in 4-6 Format

NU-National Uniform Billing Committee (NUBC) UB92 Codes

UI-U.P.C. Consumer Package Code (1-5-5)

WK-Advanced Billing Concepts (ABC) Codes SVC01-2 Service Code 1/48 Identifying number for a product or service. Example:

Procedure Code

SVC01-3 Procedure Modifier 2/2 This identifies special circumstances related to the performance of the service, as defined by trading partners. Required when a procedure code modifier applies to this service, if not do not send.




SVC01-7 Description 1/80 Procedure Code Description

SVC02 Monetary Amount 1/18 Line Item Charge Amount



SVC03 Monetary Amount 1/18 Line Item Provider Payment Amount

SVC04 Product/Service ID 1/48 National Uniform Billing Committee Revenue Code

SVC05 Quantity 1/15 Units of Service Paid Count

DTM Service Date Situational (if claim date is absent or different from service line date

DTM01 Date/Time Qualifier 3/3 “150” Service Period Start “151” Service Period End “472” Service

DTM02 Date 8/8 Date Expressed as CCYYMMDD Format

CAS Service Adjustment Situational (to account for difference in amount paid for this service)

CAS01 Claim Adjustment Group Code 1/2 “CO” Contractual Obligation “OA” Other Adjustment “PI” Payer Initiated Reductions “PR” Patient Responsibility

CAS02 Adjustment Reason Code 1/5 Claim Adjustment Reason Code

CAS03 Monetary Amount 1/18 Service Level Adjustment Amount; negative number increases amount, positive decreases

CAS04 Quantity 1/15 Numeric value of adjustment quantity

REF Service Identification Situational

REF01 Reference Identification Qualifier 2/3 Code qualifying the Reference Identification.

REF02 Reference Identifier 1/50 Provider Identifier

AMT Service Supplemental Information Situational

AMT01 Amount Qualifier Code 1/3 Code to qualify amount

AMT02 Monetary Amount 1/18 Service Supplement amount

LQ Health Care Remark Code Situational

LQ01 Code List Qualifier Code 1/3 Code List Qualifier Code. Example: “HE” Claim Payment Remark Codes

LQ02 Industry Code 1/30 Remark Code

PLB Provider Adjustment Situational

PLB01 Reference Identification 1/50 Provider Identifier

PLB02 Date 8/8 Date Expressed as CCYYMMDD. Fiscal Period End

PLB03 Adjustment Identifier To provide the category and identifying reference information for an adjustment

PLB03-1 Adjustment reason Code 2/2 Code indicating reason to invoice, debit/credit memo, or payment. Example: L6-Interest Owed FB-Forwarding Balance WO- Overpayment Recovery PI-Period Interim Payment

PLB03-2 Reference Identification 1/50 Reference information as defined for a particular transaction set to as a specific by the reference identification qualifier

PLB04 Monetary Amount 1/18 Provider Adjustment Amount

SE Transaction Set Trailer Required

SE01 Number of Included Segments 1/10 Transaction Segment Count

SE02 Transaction Set Control Number 4/9 Transaction Set Control Number. ST02 and SE02 must be identical

GE Functional Group Trailer Required

GE01 Number of Transaction Sets Included 1/6 Total number of transaction sets included in the functional group or interchange (transmission) group terminated by the trailer containing this data element.

GE02 Group Control Number 1/9 Assigned number originating and maintained by the sender. GE02 and GS06 must be identical

Interchange Control Trailer Required

IEA Interchange Control Trailer Required

IEA01 Number of the Included Functional Groups 1/5 A count of the number of functional groups included in an interchange

IEA02 Interchange Control Number 9/9 A control number assigned by the interchange sender



General Notes Data Contents and Specifications

This section describes the use of the Interchange Control segments (ISA, IEA). These segments mark the beginning and

ending of an interchange. This segment includes a description of the expected sender and receiver codes and delimiters. The

first element delimiter in the ISA segment is an Asterisk (*) which will be used as the delimiter throughout the transaction.

The final character in the ISA segment is a Tilde (~) which will be used as the delimiter for each segment in the transaction.

UCare, via Change Healthcare, has provided connectivity that complies with the Committee on Operating Rules for

Information Exchange (CORE) Safe Harbor principle (§5 Safe Harbor) according to the CORE Connectivity Phase II Rule 270.

Submitters may contact Change Healthcare for specification details.

Contact Information

Applicable Websites

www.ucare.org/providers

Providers can also contact UCare’s at:

Phone: 1-612-884-2030

Email: [email protected]

Days/Times: Monday - Friday, 8:00 a.m. – 5:00 p.m. CST

Trading Partner Agreements

Trading Partners

An EDI trading partner is defined as any UCare customer (provider, billing service, software vendor, employer group, financial

institution, etc.) that transmits electronic data to, or receives electronic data from UCare, or from a UCare contracted entity.

To ensure the integrity of the electronic transaction process, payers have EDI trading partner agreements that accompany the

standard implementation guide. The trading partner agreement is related to the electronic exchange of information, whether

the agreement is with an entity or part of a larger agreement. For example, a trading partner agreement may specify the

roles and responsibilities of each party to the agreement in conducting standard transactions.

As UCare will be directly exchanging 835 data with Change Healthcare, the existing trading partner agreement between

UCare and Change Healthcare will cover the data being passed and shared. It may be necessary for those originating these

transactions to complete trading partner agreements with Change Healthcare.

http://www.ucare.org/providers



APPENDIX

Revision History

Revision Number

Date Section Notes

1.0 1/1/2019 Original document

UCare 835 Companion Guide · 1/1/2019 · This Companion Guide is intended to describe to UCare...

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