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CMS 837P TI COMPANION GUIDECMSStandard Companion Guide TransactionInformationInstructions related to the 837 HealthCare Claim: Professionals based on ASCX12 Technical Report Type 3 (TR3),version 005010A1Companion Guide Version Number: 3.0January 30, 2018January 20181

CMS 837P TI COMPANION GUIDEPrefaceCompanion Guides (CGs) may contain two types of data, instructions for electroniccommunications with the publishing entity (Communications/Connectivity Instructions)and supplemental information for creating transactions for the publishing entity whileensuring compliance with the associated ASC X12 IG (Transaction Instructions). Eitherthe Communications/Connectivity component or the Transaction Instruction componentmust be included in every CG. The components may be published as separate documentsor as a single document.The Communications/Connectivity component is included in the CG when the publishingentity wants to convey the information needed to commence and maintaincommunication exchange.The Transaction Instruction component is included in the CG when the publishing entitywants to clarify the IG instructions for submission of specific electronic transactions. TheTransaction Instruction component content is in conformance with ASC X12’s Fair Useand Copyright statements.January 20182

CMS 837P TI COMPANION GUIDETable of ContentsTransaction Instruction (TI) . 4January 20181.TI Introduction . 41.1 Background . 41.1.1 Overview of HIPAA Legislation. 41.1.2 Compliance according to HIPAA. 41.1.3 Compliance according to ASC X12 . 41.2 Intended Use . 52.Included ASC X12 Implementation Guides . 53.Instruction Table . 5005010X222A1 Health Care Claim: Professional . 64.TI Additional Information . 224.1 Other Resources . 223

CMS 837P TI COMPANION GUIDETransaction Instruction (TI)1. TI Introduction1.1 Background1.1.1 Overview of HIPAA LegislationThe Health Insurance Portability and Accountability Act (HIPAA) of1996 carries provisions for administrative simplification. This requiresthe Secretary of the Department of Health and Human Services (HHS)to adopt standards to support the electronic exchange of administrativeand financial health care transactions primarily between health careproviders and plans. HIPAA directs the Secretary to adopt standardsfor transactions to enable health information to be exchangedelectronically and to adopt specifications for implementing eachstandardHIPAA serves to: Create better access to health insurance Limit fraud and abuse Reduce administrative costs1.1.2 Compliance according to HIPAAThe HIPAA regulations at 45 CFR 162.915 require that coveredentities not enter into a trading partner agreement that would do any ofthe following: Change the definition, data condition, or use of a data element orsegment in a standard. Add any data elements or segments to the maximum defined dataset. Use any code or data elements that are marked “not used” in thestandard’s implementation specifications or are not in thestandard’s implementation specification(s). Change the meaning or intent of the standard’s implementationspecification(s).1.1.3 Compliance according to ASC X12ASC X12 requirements include specific restrictions that prohibittrading partners from: Modifying any defining, explanatory, or clarifying contentcontained in the implementation guide. Modifying any requirement contained in the implementation guide.January 20184

CMS 837P TI COMPANION GUIDE1.2 Intended UseThe Transaction Instruction component of this companion guide must be usedin conjunction with an associated ASC X12 Implementation Guide. Theinstructions in this companion guide are not intended to be stand-alonerequirements documents. This companion guide conforms to all therequirements of any associated ASC X12 Implementation Guides and is inconformance with ASC X12’s Fair Use and Copyright statements.2. Included ASC X12 Implementation GuidesThis table lists the X12N Implementation Guide for which specific transactionInstructions apply and which are included in Section 3 of this document.Unique IDName005010X222A1 Health Care Claim: Professional (837)3. Instruction TableThis table contains rows for where supplemental instruction information is located.The order of table content follows the order of the implementation transaction setas presented in the corresponding implementation guide.Category 1. Situational Rules that explicitly depend upon and reference knowledge ofthe transaction receiver's policies or processes.Category 2. Technical characteristics or attributes of data elements that have beenassigned by the payer or other receiving entity, including size, and character setsapplicable, that a sender must be aware of for preparing a transmission.Category 3. Situational segments and elements that are allowed by the implementationguide but do not impact the receiver’s processing. (applies to inbound transactions)Category 4. Optional business functions supported by an implementation guide that anentity doesn't support.Category 5. To indicate if there needs to be an agreement between PAYER and thetransaction sender to send a specific type of transaction (claim/encounter or specific kindof benefit data) where a specific mandate doesn’t already exist.Category 6. To indicate a specific value needed for processing, such that processingmay fail without that value, where there are options in the TR3.Category 7. TR3 specification constraints that apply differently between batch and realtime implementations, and are not explicitly set in the guide.January 20185

CMS 837P TI COMPANION GUIDECategory 8. To identify data values sent by a sender to the receiver.Category 9. To identify processing schedules or constraints that are important to tradingpartner expectations.Category 10. To identify situational data values or elements that are never sent.005010X222A1 Health Care Claim: ProfessionalLoopIDJanuary 2018ReferenceNameCodesNotes/CommentsErrors identified forbusiness level editsperformed prior to theSUBSCRIBER LOOP(2000B) will result inimmediate file failure atthat point. When thisoccurs, no further editingwill be performed beyondthe point of failure.The billing provider mustbe associated with anapproved electronicsubmitter. Claimssubmitted for billingproviders that are notassociated to an approvedelectronic submitter will berejectedThe maximum number ofcharacters to be submittedin any dollar amount fieldis seven characters. Claimscontaining a dollar amountin excess of 99,999.99 willbe rejected.Medicare does not supportthe submission of foreigncurrency. Claimscontaining the 2000A CURsegment will be rejected.Claims that containpercentage amounts withvalues in excess of 99.99will be rejected.Category992426

CMS 837P TI COMPANION GUIDELoopIDJanuary 2018ReferenceNameCodesNotes/CommentsFor the exception of theCAS segment, all amountsmust be submitted aspositive amounts. Negativeamounts submitted in anynon-CAS amount elementwill cause the claim to berejected.Claims that containpercentage amounts cannotexceed two positions to theleft or the right of thedecimal. Percent amountsthat exceed their definedsize limit will be rejected.Contractor name willconvert all lower casecharacters submitted on aninbound 837 file to uppercase when sending data tothe Medicare processingsystem. Consequently, datalater submitted forcoordination of benefitswill be submitted in uppercase.Only loops, segments, anddata elements valid for theHIPAA ProfessionalImplementation Guideswill be translated.Submitting data not validbased on theImplementation Guide willcause files to be rejected.Medicare requires theNational Provider Identifier(NPI) be submitted as theidentifier for all claims.Claims submitted withlegacy identifiers will berejected. (Non-VAcontractors)National ProviderIdentifiers will be validatedagainst the NPI algorithm.Claims which failvalidation will be rejected.Category2229627

CMS 837P TI COMPANION GUIDELoopIDReferenceISA05January 2018NameInterchange ID QualifierCodes27, ZZNotes/CommentsMedicare does not requiretaxonomy codes besubmitted in order toadjudicate claims, but willaccept the taxonomy code,if submitted. However,taxonomy codes that aresubmitted must be validagainst the taxonomy codeset published athttp://www.wpcedi.com/codes/taxonomy.Claims submitted withinvalid taxonomy codeswill be rejected.All dates that are submittedon an incoming 837 claimtransaction must be validcalendar dates in theappropriate format basedon the respective qualifier.Failure to submit a validcalendar date will result inrejection of the claim or theapplicable interchange(transmission).A. You may send up tofour modifiers; however,the last two modifiers willnot be considered. TheContractors processingsystem will only use thefirst two modifiers foradjudication and paymentdetermination of claims. ORB. You may send up tofour modifiers; however,the last three modifiers willnot be considered. TheContractors processingsystem will only use thefirst modifier foradjudication and paymentdetermination of claims.Contractor will reject aninterchange (transmission)that does not contain 27 ,Category42368

CMS 837P TI COMPANION GUIDELoopIDReferenceNameISA06Interchange Sender IDISA07Interchange ID QualifierISA12Interchange Control VersionNumberGS –SegmentRuleGS –SegmentRuleGS03Application Receiver’s CodeGS04Functional Group Creation DateST –SegmentRuleJanuary 2018Codes27, ZZNotes/Commentsor ZZ in ISA05Category6Contractor will reject aninterchange (transmission)that does not contain avalid ID in ISA06.Contractor will reject aninterchange (transmission)that does not contain 27 orZZ in ISA07.Contractor will reject aninterchange (transmission)that does not contain 00501in ISA12.Contractor will onlyprocess one transactiontype (records group) perinterchange (transmission);a submitter must onlysubmit one type of GS-GE(Functional Group) withinan ISA-IEA (Interchange).Contractor will onlyprocess one type oftransaction per functionalgroup; a submitter mustonly submit one ST-SE(Transaction Set) within aGS-GE (FunctionalGroup).Contractor will reject aninterchange (transmission)that is submitted with aninvalid value in GS03(Application ReceiversCode) based on the carrierdefinition.Contractor will reject aninterchange (transmission)that is submitted with afuture date.Contractor will only acceptclaims for one line ofbusiness per transaction.Claims submitted formultiple lines of businesswithin one ST-SE66446649

CMS 837P TI COMPANION GUIDELoopIDReferenceST02NameCodesTransaction Control SetBHT02Transaction Set Purpose Code00BHT06Claim/Encounter IdentifierCH1000ANM109Submitter ID1000BNM103Receiver Name2000BHL04Hierarchical Child Code2000BSBR01Payer Responsibility SequenceNumber Code2000BSBR02,SBR09Subscriber Information2000BPAT08Patient WeightJanuary 20180P, SNotes/Comments(Transaction Set) willcause the transaction to berejected.CategoryContractor will reject aninterchange (transmission)that is not submitted withunique values in the ST02(Transaction Set ControlNumber) elements.Transaction Set PurposeCode (BHT02) must equal'00' (ORIGINAL).Claim or EncounterIndicator (BHT06) mustequal 'CH'(CHARGEABLE).Contractor will reject aninterchange (transmission)that is submitted with asubmitter identificationnumber that is notauthorized for electronicclaim submission.Contractor will reject aninterchange (transmission)that is not submitted with avalid carrier name (NM1).6The value accepted is “0”.Submission of “1” willcause your file to reject.The values accepted are“P” and “S”. Submission ofother values will causeyour claim to reject.For Medicare, thesubscriber is always thesame as the patient(SBR02 18, SBR09 MB).The Patient HierarchicalLevel (2000C loop) is notused.The maximum number ofcharacters to be submittedin the patient weight fieldis four characters to the leftof the decimal and two6665566210