837 Companion Guide

Introduction

What is HIPAA?

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 mandates the establishment of national standards for electronic transmission of health data and ensuring privacy protection. The Administrative Simplification provisions of HIPAA, Title II, require the Department of Health and Human Services to establish national standards for electronic healthcare transactions and national identifiers for providers, health plans and employers. It also addresses the security and privacy of health data. Adopting these standards improves the efficiency and effectiveness of the nation’s healthcare system by encouraging the widespread use of electronic data interchange in health care.

Falling Colors (FC), as a covered entity and payor, accepts X12 837 Professional (837P) and Institutional (837I) Health Care Claims as mandated by the administrative simplification provisions of HIPAA.

Purpose

This document has been prepared as an implementation guide to clarify when conditional data elements and segments must be used for Falling Colors reporting, and to identify those codes and data elements that do not apply to FC. This companion guide document supplements, but does not contradict any requirements in the 837 version 5010 implementation guide. This guide can be used in conjunction with the X12 implementation guide. The implementation guides for all HIPAA transactions are available from Washington Publishing Company and are available electronically to download at www.wpc-edi.com/HIPAA.

This document will be subject to revisions as new versions of the X12 837 Processional and Institutional Health Care Claim Transaction Set Implementation Guides are released.

Intended Audience

The intended audience for this document is the technical department/team responsible for submitting electronic claims transactions to Falling Colors. In addition, this information should be communicated and coordinated with the provider's billing office to ensure the required billing information is provided to their billing agent/submitted.

Transaction Submission Procedures

Submission Methods

Providers/trading partners may submit 837 claim transactions using Claim MD http://www.claim.md

Submission Procedures

Providers can enroll with Claim MD at https://www.claim.md/fallingcolors/ and submit claims via manual entry or electronic upload of an 837P or 837I. There is no cost to the provider for submitting claims directly to Falling Colors via Claim MD. (Existing Claim MD customers do not need to re-enroll, but will just submit a claim using payer ID FCC20.)

Providers can also submit claims to Claim MD via an already established relationship with their own Clearinghouse. Please ask your Clearinghouse to contact Claim MD at (855) 757-6060

Reports

Reports will be available to providers/trading partners via Claim MD using their Reporting Link.

Response Files

The following response files will be available to providers:

• 999 Implementation Acknowledgement

• 277 Healthcare Information Status Notification

• 835 Electronic Remittance Advice

Considerations

Transactions Supported (inbound)

The following inbound files will be supported:

• 837 Professional Health Care Claim

• 837 Institutional Health Care Claim

Size/Maximum Limitations

Claims files submitted in production mode cannot exceed 5000 claims (CLM segments) in any one file.

Instruction Set

The following tables contain rows for each segment that require supplemental instructions but do not contradict any requirements in the 837 version 5010 implementation guide. 

 Health Care Claim Institutional           

 Health Care Claim Professional 

 Additional Information 

• All staff administering services must be registered in the BHSDStar system along with their NPI and licensure/certification.

• Falling Colors will require a valid NPI when NM109 is used in any provider loop and will not accept Provider Secondary Identification after the mandated NPI Implementation date.

• New submitters must go through the appropriate submission procedure to transmit electronic claims with Falling Colors. Please refer to Transmission Submission Procedures Section 2.0 of this document for details.

• Falling Colors will accept 837 Institutional and 837 Professional Claims, however, the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file.

• The maximum number of medical claims accepted in a file is 5000 and the maximum number of hospital claims is 500.

• Falling Colors is adhering to structural specifications for required and situational fields. If the incoming 837I or 837P has a single ST/SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST/SEs, only the failed ST/SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgment for notification for the ST/SEs that failed.

• Falling Colors will capture payee information from the Billing Provider Name loop (Loop 2010AA). 

• Only ICD-10 Codes will now be accepted based on the regulatory compliance effective date of October 1, 2014. 

• Although the HIPAA Transaction Set technical report allows the repeating of the Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of the Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together. 

The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that Falling Colors will continue making payments to the Billing address on record in BHSDStar instead of the addresses submitted in loop 2010AB.