Title: Bill Spawning – HIPAA 837I and 837P Session : T-6-1100

1. Title: Bill Spawning – HIPAA 837I and 837P Session: T-6-1100

2. Objectives • Have a high level awareness • of the HIPAA 837I standard transaction, to include being able to understand the concept of a data segment and a data element • of what will be available in the Central Billing Events Repository • of those financial elements that will be available in the Service Enterprise Resource Planning System (such as General Fund Enterprise Business System, or GFEBS) • Understand that billing is much more than coding (and that getting a bill in the mail is less than half the work of getting the money in the “bank”)

3. Pre-Test Raise your hand as I read the statements if the statement applies to you. 1. I’ve written computer programs such as “Grand Theft Auto” – it was a piece of cake and only took 2 million hours of detailed programming 2. All programs I’ve ever used had the same password requirements; • no special characters; • with special characters but only the !&()+*-?= ; • with special characters but only @#$%<>… 3. When doing my taxes, I have ALWAYS had all the information they wanted. It has ALWAYS been called the same thing on the W2 as on the tax form.

4. What You Need to Learn Prior to Falling Asleep • The MHS does not collect some data needed for certain types of billing, and never will. • It is not cost effective. • The data would not be used by anyone else. • Get over it. • There is a lot of power in the HIPAA 837 electronic bill capability to do coordination of benefits, enter co-pay/ deductibles, and other civilian things.

5. Standard HIPAA 837 I • Think of submitting your individual taxes [HIPAA 837I] • Must be submitted with correct data in correct blanks • Taxpayer [Patient] name and demographic information • Earnings by W2 [rates for each CPT] • Deductions [co-pay, deductible] • What if you don’t have the information? • Which sections can you just skip? • Farm subsidies [type of currency] • How much does the Federal government [insurance company] owe you?

6. HIPAA 837 I Transmission Control • Communications Transport Protocol • Address of the entity sending the transmission and the address of the entity receiving the transmission • Example: Sent by central AF billing to a clearing house • Addresses are those the two parties agree upon • Matched as second to end of entire transmission by a “Communications Transport Trailer”

7. HIPAA 837I Transmission Control • Interchange Control Header • Provides the security information, such as a password or other identifying information • Date and time of interchange • Which repetition separator will be used • Interchange version number • Interchange control number • If an interchange acknowledgement is needed • If this is a test or production data • Matched as second to end of entire transmission by a “Interface Control Trailer”

8. Transmission Control • Functional Group Header and at the end Trailer • Says what kind of transaction, such as 837I, 837P, • HIPAA 837 - Health Care Claim (Professional, Institutional, Dental) • HIPAA 835 - Health Care Claim Payment/Advice Transaction • HIPAA 834 - Benefit Enrollment and Maintenance • HIPAA 270 - Health Care Eligibility/Benefit Inquiry • HIPAA 271 - Health Care Eligibility/Benefit Response • HIPAA 276 - Health Care Claim Status Request • HIPAA 277 - Health Care Claim Status Notification • HIPAA 278 - Health Care Review Information • HIPAA NCPDP DO – Retail Pharmacy

9. How Does The OUTSIDE Fit Together? Communications Transport Protocol Interchange Control Header Functional Group Header Functional Group Trailer Functional Group Header • Detail Segment – 837I Functional Group Trailer Functional Group Header • Detail Segment – 276 Functional Group Trailer Interchange Control Trailer Communications Transport Trailer Detail Segment – 837P

10. Detail Segments • HIPAA 837 - Health Care Claim • Institutional • Professional • Dental • HIPAA 835 - Health Care Claim Payment/Advice Transaction • HIPAA 834 - Benefit Enrollment and Maintenance • HIPAA 270 - Health Care Eligibility/Benefit Inquiry • HIPAA 271 - Health Care Eligibility/Benefit Response • HIPAA 276 - Health Care Claim Status Request • HIPAA 277 - Health Care Claim Status Notification • HIPAA 278 - Health Care Review Information • HIPAA NCPDP DO – Retail Pharmacy

11. Basic “Penmanship” Rules • BASIC A_Z (upper case) 0…9 (Arabic #s) • ! & () + * , - . / : ; ? = space • Extended a-z (lower case) • % ~ @ [ ] _ { } \ < > # $ • Data element separator, asterisk (*) • Sub-element separator, colon (:) • Segment terminator, tilde (~) • If transmitting in USA, usually extended set is fine – could be problems with international partners, particularly with foreign languages • For the rest of this briefing, all the lower case letters should be upper case, but are lower so you can read them more easily

12. 1000 Header • HEADER ST*837* 8675309*00510X223~ • Begin hierarchical transaction – BHT*0019*00*0123*20110309*0932*CH~ • BHT – Beginning of hierarchical transaction • “0019” – Information Source, Subscriber, Dependent • “00” – original transmission (not sent to receiver before) • 0123 – submitter’s batch control number • 20110309 – date of transmission in CCYYMMDD • 0932 – time in HHMM, so 9:32 am • “CH” – chargeable

13. 1000A Submitter • 1000A Submitter • NM1*41*2*AF Central Billing*****46*164.65.172.66~ • NM1 – a name element • “41” means submitter • “2” means non-person entity • Last name • **** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix • “46” means Electronic Transmitter Identification Number • “164.65.172.66” – our address • PER*IC*Fred Darcy*TE*7036810000~ • PER – submitter EDI contact information • “IC” means Information Contact • Fred Darcy is the free-form name • “TE” means telephone and then the number

14. 1000B Receiver • 1000B Receiver • NM1*40*2*AF Clearing House*****46*127.0.0.1~ • NM1 – a name element • “40” means RECEIVER • “2” means non-person entity • Last name • **** means I’m not using a bunch of fields, in this case the first name, middle name, prefix, suffix • “46” means Electronic Transmitter Identification Number • “127.0.0.1” – address for where we are sending the package

15. 2000A Billing – Hierarchical and Billing Provider • HL – Billing Provider Hierarchical Level • HL*1**20*1~ notice this is the 1st “HL” • 2000A Billing Provider Specialty • PRV*BI*PXC*261QM1100X~ • PRV – Billing Provider Specialty Information segment • “BI” means billing • “PXC” means health care provider taxonomy code • the HIPAA Health Care Provider Taxonomy

16. 2000A Foreign Currency Information • Situational • This will not be in the Central Billing Events Repository and probably will not be used by the billing organization • Used to specify the currency (e.g., Euro, pounds UK, dollars Canadian) used in the transaction • CUR*85*CAD~ • CUR means Currency • “85” means billing provider • “CAD” means Canada (CA is Canada, D is dollar)

17. 2010AA Billing Provider Name • NMI*85*2*56th Medical Group Luke*****XX*1194700971~ • NM1 – segment name • “85” means billing • “2” means non-person entity • 56th Medical Group Luke – last name • ***** not used first name, middle name, prefix, suffix • “XX” National Provider Identifier • 1194700971 – NPI for Luke • N3*7219 North Litchfield Road~ • N4*Luke AFB*AZ*85309~

18. 2010AA Billing Provider Name • REF*EI*as if I can even guess~ • REF – billing provider tax ID • “EI” – employer tax number • Spot for the number • PER*IC*Dane I-forget*8008675309*ex*56~ • PER – billing provider contact info segment, situational, if different from submitting info • “IC” means information contact

19. 2010AA Billing, Pay-to Address • NM1*87*2~ • “87” means “Pay-to provider” * • N3*5109 Leesburg Parkway*Suite 701*~ • N3 is the address segment detail code * • Address line • Second address line • N4*Falls Church*VA*22041~ • N4 is a city/state/zip segment detail • City • State • Zip

20. 2000B Subscriber Loops • 2000B Subscriber HL Loop • HL*2*1*22*0~ • notice this is the 2nd “HL” in the ST segment * • the HL loop to which this one is subordinate * • 22 means “subscriber” * • 0 means the subscriber is the patient and this is the only claim

21. Central Billing Events Repository Data Start HERE

22. 2000B Subscriber Loops • 2010BA Subscriber • SBR*P*18*GRP01020102******CI~ • 2010BA Subscriber name • NM1*IL*1*Doe*John*T**Jr*MI*123456~ • N3*123 Main Street~ • N4*Phoenix*AZ*85309~ • DMG*D8*19690815*M~ • REF*SY*123456789~ (subscriber 2nd ID {SY is “SSAN is next”}, situational, not required)

23. 2000B Subscriber Payer Loops • 2010BB Payer Name • NM1*PR*2*Health Inc Insurance*****PI*1234~ • PR is payer • PI is payer identification • N3*123 Main Street~ • N4*Phoenix*AZ*85309~ • REF*FY*1234~ (Reference – Payer 2nd ID, situational, not required) • FY means “claim office number” • REF*G2*1234~ (Reference – Billing Provider 2nd ID, situational, not required) • G2 means provider commercial number

24. 2000C Patient Loops • 2000C Patient HL Loop • HL*3*2*23*0~ • PAT*01~ • 01 is a spouse • NM1*QC*1*Doe*Sally*J~ • QC is that this person is the patient • N3*123 Main Street • N4*Phoenix*AZ*85309 • DMG*D8*19700607*F~ • In the patient demographic segment, the date is the birth date • F means female

25. 2300 Claim • 2300 Claim • Diagnoses! • 2310A Attending Provider • 2310B Operating Physician • 2310C Other Operating Physician • 2310D Rendering Provider • 2310E Service Facility Location • 2320 Other Subscriber Information • 2330A Other Subscriber Name

26. 2300 Claim Information • CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~ • 0009OUT201103010111 (DMIS ID 0009; outpatient;1 Mar 2010; 111th claim) is an example of a Claim Submitter’s identification of this claim, it is the patient control number, the number used to track this claim through the biller’s system • 500 is an example of the total amount of all submitted charges of service segments for this claim; this number must match the sum of all the SV2 segments

27. 2300 Claim Information • CLM*0009OUT201103010111*500***11:A:1*Y*A*Y*I~ • 11 is an example of a Facility Code Value (think Place of Service, in this case 11 is the doctor’s office) • A is the facility code qualifier for the Uniform Billing Claim Form Bill Type • 1 is the frequency of the claim (the only bill for the encounter, it covers the entire encounter) • “Y” is there for entertainment value and to confuse people, the guidance says “not used” but the example shows it • “A” the provider accepts assignment from the payer • “Y” means the patient has assigned benefits to the provider • “I” means federal law permits release of diagnosis info

28. 2300 Claim Information • DTP – Date or Time or Period • DTP*096*TM*1130~ • DTP – Date or time or period • “096” means “discharge” • “TM” means the time will be expressed in Format HHMM • 1130 is an example of 11:30 am • DTP*434*RD8*20110301-20110305~ • DTP – Date or time or period • “434” means “statement” • “RD8” means time will be CCYYMMDD-CCYYMMDD • 20110301-20110305 means 1 Mar 11-5 Mar 11

29. 2300 Claim Information • DTP – Date or Time or Period • DTP*435*DT*201103011242~ • DTP – Date or time or period • “435” means “admission” • “DT” means the time will be expressed in Format CCYYMDDHHMM • 201103011242 is an example of 1 Mar 2011 12:42 pm

30. 2300 Claim Information • CL1 – Institutional Claim Code • CL1*1*7*30~ • CL1 – institutional claim code • 1 – an admission type code (1 = emergent; 2 = urgent; 3 = elective; 4 = newborn) • 7 – an admission source code (7 = ER; 2 = clinic; 1=nonhealthcare facility point of origin) • 30 – a patient status code (see list at end of briefing) • REF*LU*MD~ • REF is a Reference identification qualifier • LU is location number for an auto accident state or province code • REF*EA*4444MN~ • EA is a medical record identification number

31. 2300 Claim Information • HI – Diagnosis information • HI*ABK:T8731*Y~ • “ABK” is ICD-10-CM principal diagnosis • “BK” is ICD-9-CM principal diagnosis • T8731 is the diagnosis for neuroma of amputation stump, right upper extremity • Y” is “yes” in the Present on Admission Indicator • HI*ABJ:T8741*Y~ • “ABJ” is ICD-10-CM admitting diagnosis • “BJ” is ICD-9-CM admitting diagnosis • T8731 is the diagnosis for neuroma of amputation stump, right upper extremity • HI*APR:R110~ • “APR” is ICD-10-CM reason for outpatient visit

32. 2300 Claim Information • HI • HI*ABN*T560X1*Y*ABN*W3301*Y~ • “ABN” is ICD-10-CM external cause of injury • T560X1 is Toxic effect of lead and its compounds, accidental • “Y” is yes for the Present on Admission Indicator • “ABN” is for the additional ICD-10-CM external cause of injury • W3301 is Accidental discharge of shotgun • “Y” is yes for the POA indicator • HI*DR:123~ • “DR” is diagnosis related group • HI*ABF:J151*Y~ • “ABF” is ICD-10-CM other diagnosis

33. 2300 Claim Information • HI*BBR:0B110F4:D8:20110302~ • “BBR” is the ICD-10-PCS principal procedure • 0B110F4 is Tracheostomy device inserted to trachea, open, to outside (cutaneous) • D8 is that a date in the CCYYMMDD format follows • HI*BBQ:02130KF:D8:20110304*BBQ:4A023N8:D8:20110304~ • BBQ is other ICD-10-PCS procedures • D8 is that a date in the CCYYMMDD format follows

34. 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository PWK – Claim supplemental information (paperwork) AMT – Patient estimated amount due REF – Service authorization exception code (for example if it was an emergency which is why there was no pre-authorization REF – Referral number (for example a payer provided a referral number for so many physical therapy encounters)

35. 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository REF – Prior authorization (for example for major surgery) REF – Investigational device exemption number REF – Demonstration Project Identifier REF – Peer Review Organization Approval Number NTE – Claim note or a Billing Note (used when the provider wants to indicate there is additional information needed to substantiate medical treatment)

36. 2300 Claim Information NOT in CBER Segments that are available but would not be in the Central Billing Events Repository HI*BI – Occurrence span information HI*BH – Occurrence information HI*BE – Value information HI*BG – Condition information HI*TC – Treatment code condition (used for home health agencies)

37. 2310A Attending Provider Name • NM1*71*Jones*John****XX*1357986420~ • “71” in this position is “attending physician” • XX is “the NPI is next” • PRV*AT*PXC*208D00000X~ • PRV is attending provider specialty segment • “AT” is attending • “PXC” is “the HIPAA Health Care Provider Taxonomy is next”

38. 2310 Additional Providers • 2310B NM1*72*1*Meyers*Jane*****XX*1357986420~ • “72” is operating physician • XX is “the NPI is next” • Is only used if there is a surgical procedure on the claim • 2310C NM1*ZZ*1*Doe*John*A***XX*1357986420~ • “ZZ” is mutually defined to indicate “other operating physician” • Usually not needed, usually only one surgeon • 2310D NM1*82*1*Doe*Jane*C***XX*1357986420~ • “82” is rendering provider

39. 2310E Service Facility • 2310E • NM1*77*2*Bolling Clinic*****XX*1468097532~ • “77” is Service Location (other than the doctor’s office) • “2” is non-person entity • N3*1300 Angell Street~ • N4*Bolling AFB*DC*20032~

40. 2310F Referring Provider NOT in CBER • NOT in the Central Billing Event Repository, but could be for civilian sector • NM1*DN*1*Welby*Marcus*W**Jr*XX*1246809753~ • “DN” is referring provider • “1” is a person • XX is “the NPI is next”

41. 2320 Other Subscriber Information • SBR*S*01*GR00786******13~ • SBR is a subscriber information segment • “S” is secondary coverage • “01” is that the spouse is the one with the coverage • “GR00786” is an example of a insured group or policy number • “13” is a claim filing indicator code representing “point of service” – eventually this will go away when HIPAA National Plan IDs are fielded

42. Claim Adjustments, Repricing…NOT in CBER • Claim adjustments, repricing, coordination of benefits (COB) payer paid amount, remaining patient liability, adjudication information, check remittance date, and other post bill generation activities will not appear in the Central Billing Events Repository (CBER). • These activities will be done by the Service billing/collections activity. • Collections, adjustments, repricing, co-pays, deductibles etc., will be tracked in the Service Enterprise Resource Planning (ERP) system.

43. 2330B Other Payer Name • NM1*PR*2*Another Insurance Group*****PI*1123344~ • “PR” is payer • “2” is non-person entity • “PI” is payer identification • N3*100 N Broadway*Suite 10B~ • N4*New York City*NY*10008~ • Other payer information such as provider name, operating physician and service facility will not be in the CBER as these data elements are not collected and stored centrally

44. 2400 Loops 2400 Service Line 2420C Rendering Provider 2420D Referring Provider

45. 2400 Services Provided • LX*1~ • LX is a service line number segment • SV2*0300*HC:81099*73.42*UN*1~ • SV2 is a institutional service line segment • 0300 is an example of a revenue code for the laboratory • “HC” is a HCPCS code (includes CPT) • “81099” is a HCPCS lab unspecified code • “73.42” is the price billed • “UN” is “unit” • “1” is a quantity

46. 2400 • DTP*472*D8*20110302~ • DTP is date or time or period segment • “472” is a service • D8 indicates date format will be CCYYMMDD • 20110302 is 2 Mar 11

47. Transaction Set Trailer NOT in CBER • Would not be in the CBER, this is done when the HIPAA transaction is sent to the clearing house • SE*1230*8675309~ • SE is a transaction set trailer • 1230 is the number of segments included in the transaction including ST and SE segments • 8675309 is the same transaction set control number in the ST02 that began the transaction

48. Transaction Set Trailer NOT in CBER Again, this would not be in the Central Billing Events Repository – it is something used by the billing organization to make sure the “box of bills” are sent to the correct clearing house (e.g., FedEx) Then the clearing house re-directs the data to the payer

49. Business Usage • Coordination of Benefits • The CBER will list all the known possible payers based on what is in the Other Health Insurance file and the PATCAT (patient category, such as Coast Guard) • Billing entity needs to determine when there is a primary and secondary payer, will the bill go to • The first payer who enters what he paid, and the first payer send it directly to the second payer • The first payer send back his remittance, then you need to enter the 1st payer’s input and send to the second payer

50. Capturing The Data • Encounter Data • Patient Registration • At the MTF entering the patient initially in the CHCS registration module will “bring down” the patient data (e.g., birthday, gender, EDI-PN) from DEERs • Appointment Module • To make an appointment there must be a “file and table build” where the provider data (e.g., NPI and HIPAA taxonomy) are stored • Also will collect the date/time of the scheduled appointment and the DMIS ID • Inpatient Module • Assigns the medical record number, links the provider file information