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5010 Health Care Claim Encounter Standard V3.2

UHIN STANDARDS COMMITTEE

Approved

 

UHIN STANDARDS COMMITTEE

Version 3.2

5010 Health Care Claim/Encounter Standard

 

UHIN Health Care Claim/Encounter Standard is compatible with all HIPAA requirements.

 

Purpose:  The purpose of this Standard is to detail the Standard transactions for the transmission of health care claims and encounters and associated transactions in the state of Utah.

 

Applicability:  This Standard applies to professional, institutional, and dental electronic claims in the state of Utah after March16, 2009.  The Standard may be adopted voluntarily prior to that date.

 

Detail:

  1. Standard Claim Transactions:

The UHIN Standard for electronic claims/encounters is the

  •     HIPAA ASC X12 837 005010X222A1 Professional Implementation Guide for professional claims/encounters
  •     HIPAA ASC X12 837 005010X223A2 Institutional Implementation Guide for institutional claims,
  •     HIPAA ASC X12 837 005010X224A2 Dental Implementation Guide for dental claims/encounters.

 

See the Washington Publishing Company web site (http://www.wpc-edi.com) to download a copy of the implementation guides in Adobe Acrobat.

 

  1. Claim Acknowledgement Transactions:

All trading partners will utilize the ASC X12 999 Functional Acknowledgement to acknowledge receipt of batch transactions and to report any syntactical errors.  All trading partners must be able to both send and accept 999 transactions.  See UHIN Functional Acknowledgement Standard for details on the use of the 999.

 

Payers will utilize the ASC X12 277 Claim Acknowledgement 005010x212 Implementation Guide Claim Acknowledgement report on a batch-for-batch basis (837 batch to 277).  See UHIN Claim Acknowledgement Standard for details on the use of the 277CA.

 

  1. Provider-Assigned Claim Control Number:

The Patient Control Number (provider-assigned claim control number, CLM01) is used for matching claim to payment. This number must be unique to the provider in order to associate payment data.

 

  1. Interchange Control Number:

The translator will assign the ICN (Interchange Control Number), GS06.  Providers must be able to view the ICN after transmission to allow for batch matching (277CA to 837).

 

  1. Translators will utilize the HIPAA implementation guides use edits.

 

  1. Resubmitted/corrected claims/encounters

A resubmitted or corrected claim/encounter is one which uses the value of “7” in CLM05-3. 

Payers may reject such claims/encounters if the payer trace number is not included in the resubmitted/corrected claim (Loop ID-2300, REF01=G8), or if the payer trace number included in the claim/encounter is incorrect (e.g., a payer claim/encounter number which was assigned to a different provider).  See UHIN Claim Acknowledgement Standard – 277CA for claim status codes to communicate these rejections.

 

 

  1. Provider Identifier:

All eligible providers must submit the National Provider Identifier in appropriate segments.  See UHIN National Provider Identifier Standard for NPI usage.

 

A-Typical Providers must submit the Payer Assigned Identifier (Legacy) in appropriate segments.  See UHIN National Provider Identifier Standard for A-Typical identifier usage.

 

  1. Clearinghouse submissions:

To facilitate claim tracking using the 277CA, clearinghouses must create a batch (ST-SE) for each Billing/Payto Provider.  When the claim file is created in this manner the payer will be able to respond in a Batch to Batch method with the 277CA. 

 

 

IMPLEMENTATION ISSUES:

  1. Payers, providers, and transmission intermediaries (clearinghouses, VANs, repricers, etc) will make the necessary modifications to enable this transaction.

 

  1. The implementation date for this Standard is January 1, 2012.

 

 

History: (MM/DD/YY)

 

Original

V3

A3.2

A 5

A 6

ORIGINATION DATE

 

04/14/09

02/09/2011

 

 

APPROVAL DATE

 

08/05/09

05/18/2011

 

 

EFFECTIVE DATE

 

09/05/09

06/18/2011

 

 

* A = Amendment

 

 

 

 

 

 

 

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