837P ACUTE CARE COMPANION GUIDE 5010 - TMHP
837P Health Care Claim: ProfessionalTexas MedicaidHIPAA TransactionStandard Companion GuideRefers to the Implementation GuideAcute Care 837 Health CareClaim: ProfessionalBased on ASC X12 version 005010CORE v5010 Companion Guide
837P Health Care Claim: ProfessionalDisclosure StatementCopyright 2016 by Texas Medicaid. All rights reserved. It may be freely redistributed in its entiretyprovided that this copyright notice is not removed. It may not be sold for profit or used in commercialdocuments without the written permission of the copyright holder. This document is provided “as is”without any expressed or implied warranty. Note that the copyright on the underlying AccreditedStandards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association(DISA) on behalf of ASC X12.Texas MedicaidPage 1 of 45
837P Health Care Claim: ProfessionalPrefaceThis Companion Guide to the v5010 ASC X12N Implementation Guide and associated errata adoptedunder Health Insurance Portability and Accountability Act of 1996 (HIPAA) clarifies and specifies thedata content when exchanging electronically with Texas Medicaid. Transmissions based on thisCompanion Guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliantwith both ASC X12N syntax and those guides. This Companion Guide is intended to conveyinformation that is within the framework of the ASC X12N Implementation Guides adopted for useunder HIPAA. The Companion Guide is not intended to convey information that in any way exceedsthe requirements or usages of data expressed in the Implementation Guides.Texas MedicaidPage 2 of 45
837P Health Care Claim: ProfessionalEDITOR’S NOTE:This page is intentionally left blank.Texas MedicaidPage 3 of 45
837P Health Care Claim: ProfessionalTable of Contents1.INTRODUCTION . 5Scope 5Overview . 5References . 6Additional Information . 62.GETTING STARTED . 7Working with Texas Medicaid . 7Trading Partner Registration . 73.TESTING WITH TEXAS MEDICAID . 84.CONNECTIVITY WITH TEXAS MEDICAID/COMMUNICATIONS . 8Transmission Administrative Procedures . 8Communication protocol specifications . 8Passwords. 85.CONTACT INFORMATION . 9Customer Service . 9Applicable websites/e-mail. 96.CONTROL SEGMENTS/ENVELOPES. 10ISA-IEA . 10GS-GE 117.TEXAS MEDICAID SPECIFIC BUSINESS RULES AND LIMITATIONS . 12PWK05 Paperwork Identifier Definition . 12NTE02 Claim Note Description Definition . 14CAS02 Texas Medicaid Disposition Code Chart . 178.ACKNOWLEDGEMENTS AND/OR REPORTS . 299.TRADING PARTNER AGREEMENTS . 29Trading Partners . 2910.TRANSACTION SPECIFIC INFORMATION . 3111.APPENDICES . 40Transmission Examples . 40Change Summary . 42Texas MedicaidPage 4 of 45
837P Health Care Claim: Professional1. INTRODUCTIONScopeUnder the Administrative Simplification provisions of the Health Insurance Portability andAccountability Act (HIPAA) of 1996, the Secretary of the Department of Health and HumanServices (HHS) is directed to adopt standards to support the electronic exchange ofadministrative and financial health care transactions. The purpose of the AdministrativeSimplification portion of HIPAA is to enable health information to be exchanged electronicallyand to adopt standards for those transactions.Texas Medicaid defines a Trading Partner as any entity trading data with Texas Medicaid EDI.Trading partners include vendors, clearinghouses, Providers and billing agents.The 5010 Technical Report Type 3 (TR3) dated May 2006 was used to create this CompanionGuide for the 837 file format. All instructions in this document are written using informationknown at the time of publication and are subject to change.OverviewThis guide is intended as a resource to assist submitters in successfully conducting EDI 837Health Care Claims: Professional transactions with Texas Medicaid. This document does notprovide detailed data specifications, which are published separately by the industry committeesresponsible for their creation and maintenance.The purpose of this document is to assist the provider with Texas Medicaid-particular data setsfor information specified in the National Electronic Data Interchange Transaction SetImplementation Guide for the file type. The federal government has set standards to simplifyElectronic Data Interchange (EDI). To comply with the standard, Texas Medicaid has updatedthe data sets for EDI files to be in accordance with HIPAA and is utilizing the ASC X12nomenclatures.The instructions in this companion guide are not intended to be stand-alone requirementsdocuments, and must be used in conjunction with the associated ANSI ASC X12N NationalImplementation Guide. This companion guide conforms to all the requirements of anyassociated ASC X12 Implementation Guide and is in conformance with ASC X12’s Fair Useand Copyright statements.Texas MedicaidPage 5 of 45
837P Health Care Claim: ProfessionalReferencesThe ANSI ASC X12N Implementation Guides are available for purchase at the WashingtonPublishing Company web site at: datedguides.The Texas Medicaid EDI Connectivity Guide which contains instructions regarding connectivityoptions including CORE compliant Safe Harbor information can be found on the EDI page ofthe Texas Medicaid website at: http://www.tmhp.com/Pages/EDI/EDI Technical Info.aspx.The Companion Guides, published by Texas Medicaid can be found onhttp://www.tmhp.com/Pages/EDI/EDI companion guides.aspxAdditional InformationSecurity and Privacy StatementCovered entities were required to implement HIPAA Privacy Regulations no later than April 14,2003. A covered entity is defined as a health plan, a health care clearinghouse, or a healthcare provider who transmits any health information in electronic form in connection with aHIPAA transaction. Providers that conduct certain electronic transmissions are responsible forensuring these privacy regulations are implemented in their business practices. Health andHuman Services Commission (HHSC) is a HIPAA Covered Entity. Accordingly, TexasMedicaid is operating as a HIPAA Business Associate of HHSC as defined by the federallymandated rules of HIPAA. A Business Associate is defined as a person or organization thatperforms a function or activity on behalf of a covered entity, but is not part of the coveredentity's workforce. The privacy regulation has three major purposes:To protect and enhance the rights of consumers by providing them access to their healthinformation and controlling the appropriate use of that information;To improve the quality of health care in the United States by restoring trust in the health caresystem among consumers, health care professionals and the many organizations andindividuals committed to the delivery of health care; andTo improve the efficiency and effectiveness of health care delivery by creating a nationalframework for health privacy and protection.Texas MedicaidPage 6 of 45
837P Health Care Claim: Professional2. GETTING STARTEDWorking with Texas MedicaidThis section describes how to interact with Texas Medicaid’s Electronic Data Interchange (EDI)systems.EDI Help Desk is available to assist trading partners in exchanging data with Texas Medicaid.Below are details on how to register and contact the department for assistance.Trading Partner RegistrationHHSC requires any entity exchanging electronic data with Texas Medicaid to be enrolled in theTexas Medicaid Program and approved for the submission of X12 transaction sets.Texas Medicaid Enrollment Forms and instructions are available at:http://www.tmhp.com/Pages/SupportServices/PSS Home.aspxSuccessful enrollment in Texas Medicaid is required before proceeding with EDI.To get started with EDI transactions, the necessary forms and instructions are available at:http://www.tmhp.com/Pages/EDI/EDI Forms.aspxTexas MedicaidPage 7 of 45
837P Health Care Claim: Professional3. TESTING WITH TEXAS MEDICAIDTexas Medicaid requires that all Trading Partners who connect directly to successfullycomplete the testing process prior to submitting claims.If the Provider or Billing Agent utilizes a Clearinghouse to submit the electronic claims, theentity connecting with Texas Medicaid must have successfully completed the testing processprior to claim submission.Texas Medicaid provides a self-testing tool through Edifecs. Testing and Certificationinstructions, along with setup information can be found in Section 9.1 of the Texas MedicaidEDI Connectivity Guide found at:http://www.tmhp.com/TMHP File . CONNECTIVITY WITH TEXAS MEDICAID/COMMUNICATIONSTransmission Administrative ProceduresThe Texas Medicaid EDI Connectivity Guide that contains specific instructions regardingconnectivity options, can be found on the EDI page of the Texas Medicaid website at:http://www.tmhp.com/Pages/EDI/EDI Technical Info.aspxCommunication protocol specificationsThe Texas Medicaid EDI Connectivity Guide that contains specific instructions regardingconnectivity options, along with CORE compliant Safe Harbor information, can be found on theEDI page of the Texas Medicaid website at:http://www.tmhp.com/Pages/EDI/EDI Technical Info.aspxPasswordsTexas Medicaid provides instruction on resetting of passwords in section 5.1 of the TexasMedicaid EDI Connectivity Guide found at:http://www.tmhp.com/TMHP File exas MedicaidPage 8 of 45
837P Health Care Claim: Professional5. CONTACT INFORMATIONCustomer ServiceTexas Medicaid EDI Help DeskThe EDI Help Desk provides technical assistance only by troubleshooting Texas Medicaid EDIissues. Contact your system administrator for assistance with network, hardware, or telephoneline issues.To reach the Texas Medicaid EDI Help Desk, select one of the following methods: Fax 1-512-514-4230 or 1-512-514-4228Call 1-888-863-3638, option 3 (or call 1-512-514-4150, option 3)The Texas Medicaid EDI Help Desk is available Monday through Friday, 7 a.m. to 7 p.m. CST.Applicable websites/e-mailThis section contains detailed information about useful web sites and email addresses.Texas Medicaid EDI Technical Information, such as code references, vendor file specifications,and additional Companion Guides can be found at:http://www.tmhp.com/Pages/EDI/EDI Technical Info.aspxThe Texas Medicaid Provider Procedures Manual is found at:http://www.tmhp.com/Pages/Medicaid/Medicaid Publications Provider manual.aspxEDI Helpful Links:Washington Publishing Company - The Washington Publishing Company site includesreference documents pertaining to HIPAA, such as: implementation guides, data conditions,and the data dictionary for X12N standards.Workgroup for Electronic Data Interchange (WEDI) - This site provides implementationmaterials and information.National Uniform Billing Committee (NUBC) – This site is the official source of UB-04 billinginformation.Texas Department of Aging and Disability Services (DADS)Texas Department of State Health Services (DSHS)Texas Health and Human Services CommissionTexas MedicaidPage 9 of 45
837P Health Care Claim: Professional6. CONTROL SEGMENTS/ENVELOPESISA-IEA Texas Medicaid does not support repetition of a simple data element or a compositedata structure. Texas Medicaid will accept one ISA/IEA in each file and one GS/GE per ISA. Texas Medicaid uses “*” (asterisk) as the element separator, and “ ” (tilde) as thesegment separator.Page LoopReference#IDControl SA07NameInterchangeControl ormationQualifierInterchange IDQualifierInterchangeSender IDInterchange IDQualifierCodesLengthNotes/Comments0000ZZProvider SubmitterIDZZAcute Care ClaimsProduction 617591011C21PTesting 617591011C21TC.5ISA08C.5ISA11C.6C.6C.6Texas MedicaidISA14ISA15ISA16InterchangeReceiver hangeUsage IndicatorComponentElementSeparatorLTSS (Long TermServices andSupport) ClaimsProduction 617591011LTSSPTesting 617591011LTSST (pipecharacter)0 (zero)PISA15 ”P” for bothProduction and Test: (coloncharacter)Page 10 of 45
837P Health Care Claim: ProfessionalGS-GEPage LoopReference#IDControl SegmentsGSC.7C.7C.7GS02GS03NameFunctionalGroup HeaderApplicationSender’s mmentsIdentical to ISA06Identical to ISA08.Texas MedicaidPage 11 of 45
837P Health Care Claim: Professional7. TEXAS MEDICAID SPECIFIC BUSINESS RULES ANDLIMITATIONSTexas Medicaid will accept up to 5000 transactions per batch. If a file is submitted with morethan 5000 transactions the entire file will be rejected and not processed by Texas Medicaid.X12 files with more than one GS-GE Functional Group will fail to process in the TexasMedicaid system.The Texas Medicaid Provider Procedures Manual is the providers’ principal source ofinformation about Texas Medicaid. The most recent version is found at:http://www.tmhp.com/Pages/Medicaid/Medicaid Publications Provider manual.aspx.PWK05 Paperwork Identifier DefinitionTexas Medicaid has specific qualifiers that must be used when transmitting other insuranceinformation. Please utilize the following qualifiers for the PWK01 and PWK02:1832300PWK01Attachment ReportType CodeEBExplanation ofBenefits(Coordination ofBenefits or MedicareSecondary tronically onlyThe PWK06 is broken down below. In order for Texas Medicaid to recognize the otherinsurance information, the data structure below must be adhered to.Texas Medicaid requires that the submitter use V5X and V5Y as the first 3 characters of thisdata element (s) to indicate that a denial has been received verbally from an insurancecompany. Verbal Denials required additional information regarding the insurance company andcontact information about the verbal statement.NOTE: x – the rest of the value after the requirementQualifiers V5X and V5YRequired if other insurance gave a verbal denial.Send in the following format:First PWK Segment:Position 1-3 V5XPosition 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance dispositionPosition 5 spacePosition 6-15 Phone NumberPosition 16 spacePosition 17- 41 name of insurance representativePosition 42 spacePosition 43 – 50 date of inquiry in CCYYMMDD formatSecond PWK Segment:Position 1-3 V5YPosition 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance disposition (Must be the same as position 4 of V5X)Position 5 – 34 Reason given for denialTexas MedicaidPage 12 of 45
837P Health Care Claim: ProfessionalQualifiers A5Q and A5RInsurance company information required if other insurance was billed. Send in the followingformat:First PWK Segment:Position 1-3 A5QPosition 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance dispositionPosition 5-14 Phone NumberPosition 15 – 32 Ins. Co. AddressSecond PWK Segment:Position 1-3 A5RPosition 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance disposition (Must be the same as position 4 ofA5Q)Position 5 – 24 Ins. Co. CityPosition 25 – 26 Ins. Co. StatePosition 27 – 35 Ins. Co. ZipQualifier B8ZPosition 1 – 3 B8ZTexas Medicaid requires that for insurance disposition the submitter follow the below segmentlayout:Position 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance dispositionPosition 5 – 12 date in CCYYMMDD format follow the below segment layout:Position 4 indicate 1 if relevant to 1st other insurance disposition, 2 if for 2nd other insurancedisposition, and 3 if for 3rd other insurance dispositionPosition 5 – 12 date in CCYYMMDD formatTexas MedicaidPage 13 of 45
837P Health Care Claim: ProfessionalNTE02 Claim Note Description DefinitionVision:Texas Medicaid requires that submitters send vision prescription data in the NTE segment associatedwith the first service line on the claim. The submitter should follow the below NTE02 field layout:Position 1 through 5: new prescription right sphere,Position 6 through 10: new prescription right cylinder,Position 11 through 15: new prescription near right,Position 16 through 20: new prescription intermediate right,Position 21 through 25: new prescription left sphere,Position 26 through 30: new prescription left cylinder,Position 31 through 35: new prescription near left,Position 36 through 40: new prescription intermediate left,Position 41 through 45: old prescription right sphere,Position 46 through 50: old prescription right cylinder,Position 51 through 55: old prescription near right,Position 56 through 60: old prescription intermediate right,Position 61 through 65: old prescription left sphere,Position 66 through 70: old prescription left cylinder,Position 71 through 75: old prescription near left,Position 76 through 80: old prescription intermediate left.Family Planning:Texas Medicaid requires submitters send family plannin
Standard Companion Guide Refers to the Implementation Guide Acute Care 837 Health Care Claim: Professional Based on ASC X12 version 005010 CORE v5010 Companion Guide . 837P Health Care Claim: Professional Texas Medicaid Page 1 of 45 Disclosure Statement .
Standard Companion Guide . Health Care Claim: Professional (837P) Based on ASC X12N Implementation Guide, Version 005010X222A1 . Companion Guide Version Number: 6.1, May 2020 . CMS 837P Version 005010 Companion Guide ii . CMS 837P Version 005010 Companion Guide iii
chronic care needs that result in frequent transitions between their homes, acute, post-acute, and long-term care settings. In 2008, almost 40 percent (38.7%) of all Medicare beneficiaries discharged from acute-care hospitals received post-acute care. Of these beneficiaries, 15.5 percent were readmitted to the acute care hospital within 30 days 1
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