EDI Claims Companion Guide for 5010 BMC HealthNet Plan

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Table of Contents,Introduction 3,Important Reminders 4. Submitting Electronic Claims 6,Contacts 6, Establishing Direct Connectivity with BMC HealthNet Plan 8. Reporting 11,Reporting Summary 15,Operational Requirements Summary 16. Electronic Replacement and Void requests 18, BMC HealthNet Plan Specific Conditional Data Requirements 20. Professional Claims 837P Data Requirements 20,Institutional Claims 837I Data Requirements 24.
Appendices 28, Appendix A Control and Identifier Segments for the 837P and 837I files 28. ISA Interchange Control Header Segment 28,GS Functional Group Header Segment 29. Submitter Receiver Name Loops 29, Appendix B Professional CMS 1500 Claims Mapping to 837P format 30. Appendix C Institutional UB 04 Claims Mapping to 837I format 33. Page 2 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Introduction, In order to make claims submission easier for providers and for required compliance. with the Health Insurance Portability and Accountability Act s HIPAA s. Transaction and Code Set standards we process electronic claims in the X12N 837. version 5010 Errata format, Electronic claims can be submitted directly to the Plan or via clearinghouses and.
billing agencies see the Contacts section for more information. HIPAA requires that the Plan and all other health insurance payers in the United. States comply with electronic data interchange standards for health care as. established by the Secretary of Health and Human Services The X12N 837 version. 5010 Errata implementation guides for Health Care Claims have been established as. the standard for claims transactions compliance The implementation guides for this. format are available electronically at http www wpc edi com. This document has been prepared as a BMC HealthNet Plan specific companion. document to that implementation guide and will clarify when conditional data. elements and segments must be used for BMC HealthNet Plan reporting It also will. identify those situations and data elements that do not apply to BMC HealthNet Plan. This companion guide document supplements but does not supercede any. requirements in the 837 version 5010 Errata implementation guides. The intended audiences for this document are the billing departments and the. technical areas responsible for submitting electronic claims transactions to the Plan. In addition this information should be communicated to and coordinated with the. provider s billing office in order to ensure that the required billing information is. provided to the billing agent submitter, Page 3 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Important Reminders, To ensure that your claims are processed through to adjudication. 1 The Plan can accept ICD 10 codes with upper case characters only and without. decimal points Claims submitted with both ICD 9 and ICD 10 diagnosis codes. will be denied Please see our website for more info about submitting ICD 10. codes http www bmchp org providers claims icd 10 info. 2 In accordance with HIPAA rules BMC HealthNet Plan accepts the National. Provider Identifier NPI Please note that all NPIs must be registered with the. Plan In addition the Plan reads NPIs in combination with tax IDs or Social. Security numbers tax IDs take precedence to identify rendering providers so we. must have that combination on file for adjudication purposes except in certain. Behavioral Health or specialty situations depending on providers contracted. situations Visit our website to learn how to submit your NPI information. http www bmchp org pages providers provider hipaa npi information aspx. 3 If your NPI and or Tax ID is not provided or is not in the correct place the claim. will be rejected Your rendering servicing provider NPI must be in the equivalent. of UB 04 Form Locator 51 or CMS 1500 Box 24J or CMS 1500 Box 33 Please. note 5010 compliance rules state that if the rendering provider information is the. same as the billing provider information rendering provider information should. not be sent in the 837 Please see Appendices B and C for valid locations for the. BMCHP Provider ID on the 837 format, 4 A valid Plan assigned member identification number e g a B number such as. B12345678 must be provided If this number is not provided or is in the wrong. place the claim will be rejected Please see Appendices B and C for valid. locations for the member ID on the 837 format Please note that claims for. members of our Employer Choice Commonwealth Choice plans should include. the two digit suffix e g C1234567801, 3 Modifiers must be appended to the CPT HCPCS codes in the line items where. they apply, 4 Claims requiring attachments e g EOBs invoices etc cannot be submitted via.
EDI at this time, 5 Anesthesia claims must use ASA codes Units must be in minutes not in. fractions of hours or days, 6 BMC HealthNet Plan can accept claim replacement frequency code 7 and void. frequency code 8 transactions in the 837 formats but adjustments or voids of. any claims that have been split MUST be submitted on paper See Page 18 for. Page 4 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. 7 BMC HealthNet Plan accepts 837 Institutional and 837 Professional files written. to the 5010 Errata specifications 005010X223A2 for 837I 005010X222A1 for. 8 BMC HealthNet Plan can accept 25 total diagnosis codes for 837I UB 04 claims. and 12 total diagnosis codes for 837P CMS 1500 claims. 9 The filenames of electronic claims files can be no longer than 50 characters. including the extension, 10 Claims with information in the 2320 Other Subscriber Information and 2330A. through 2330I Other Subscriber Name Other Payer Billing Provider loops may. pend for COB investigation thus if your claims generation software populates. those loops with information that matches the subscriber data Loop 2010BA the. claim might be pended and delayed even though there is really no COB. SBR P 18 81720500151 MC MC,DMG D8 YYYYMMDD M,NM1 IL 1 LASTNAME FIRSTNAME MI B12345678. N3 STREET ADDRESS,N4 CITY MA 0000 REF SY 123456789.
NM1 PR 2 MEDICAID PI MASSHEALTH, 11 NDC codes required effective with 6 1 2012 date of service. To meet compliance standards outlined in the Deficit Reduction Act DRA of. 2005 and the Commonwealth of Massachusetts regulations effective with date of. service June 1 2012 BMC HealthNet Plan the Plan will require the 11 digit. national Drug Code Number NDC to be reported on all qualifying claim forms. when injectable physician administered drugs are administered in the office or an. outpatient setting this requirement excludes applicable vaccines immunizations. Providers will need to submit claims with both HCPCS and NDC codes to the. Plan with the exact NDC that appears on the medication packaging in the 5 4 2. digit format i e xxxxx xxxx xx as well as the NDC units and descriptors This. coding requirement will apply only to all BMC HealthNet Plan MassHealth. members Failure to submit the exact applicable NDC number units and. descriptors administered to the MassHealth member will result in a front end. rejection and or denial of the claim line that required NDC reporting. For more information please see Network Notification M 131 dated March 27. 2012 on our web site http www bmchp org providers network notifications. Page 5 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Submitting Electronic Claims, BMC HealthNet Plan currently accepts and processes provider claims electronically. for all providers and billing agencies who submit claims directly to us or who use. Allscripts PayerPath Capario Emdeon Gateway EDI RelayHealth the SSI Group. NEHEN the New England Healthcare Exchange Network or a billing agency If. you or your billing agency uses one of these clearinghouses contact the appropriate. person below,Type of Payer Telephone,Contact Name Email Address. Connection ID Number,Sheba Kelly ITOpsSupport,DIRECT N A 617 478 3538 BMCHP. IT Ops Support,BMC HealthNet Plan wellsense org,Existing Allscripts.
clients Allscripts,Clearinghouse,providers should,Allscripts contact their Allscripts. support team,allscripts com,Non clients,800 334 8534. Existing Capario clients,800 792 5256 edi,Clearinghouse Capario Provider. option 2 capario com,Capario Services,Non clients,providersales. capario com Capario Provider Sales 800 586 6870,capario com.
Department,Existing Emdeon clients,Contact your vendor to. Clearinghouse have BMC HealthNet,Emdeon 13337 Plan added to your Payer. emdeon com,Non clients,866 369 8805 Physicianinfo,Emdeon Sales emdeon com. Clearinghouse,Gateway EDI salescontact,13337 General info line 800 969 3666. gatewayedi com,gatewayedi com,NEHEN Existing NEHEN clients.
NEHENNet Contact your site 781 290 1290 nehennet csc co. administrator m, Page 6 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. nehen org N A Non clients neheninfo,781 290 1290,nehennet org Sales department nehennet org. Page 7 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Type of Payer Telephone,Contact Name Email Address. Connection ID Number,Clearinghouse Most existing,RelayHealth RelayHealth providers. using RelayHealth,relayhealth com ge Clearinghouse Services.
neral should contact their,contactUs practice management. system vendor for,Providers working with,RelayHealth directly on. support or enrollment,matters should contact,2921 800 522 6562 or the. 837I ePREMIS support line,To add payer,connectivity to BMC. HealthNet Plan,providers can reference,the payer list on.
Collaboration Compass,and or add a payer as,they generally would. based on their system set,Sandy D Hickman,251 345 0000 Sandy Hickman. EDI Payer Development,ext 1254 ssigroup com,Clearinghouse Coordinator. SSI Group Joan Kossow,0515 251 345 0000 joan kossow. Data Compliance,ext 1218 ssigroup com,thessigroup com Manager.
edi operations,Datacenter Group 800 880 3032,ssigroup com. Clearinghouse,David Meier 502 238 9231,13337 david meier. zirmed com zirmed com, Page 8 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Establishing Direct Connectivity with,BMC HealthNet Plan. This section addresses connectivity and the transmission of electronic transactions to. BMC HealthNet Plan, To establish EDI directly with the Plan contact the Plan representative listed above.
under Contacts Direct, Due to patient confidentiality and HIPAA regulations all transmissions must be. BMC HealthNet Plan s methods of transmission are,1 Secure FTP via SSL AUTH TLS FTPS or SFTP. 2 Standard FTP using PGP file encryption The free Open Source version known. as GnuPG http www gnupg org is also acceptable, We will establish a secured individual FTP directory at BMC HealthNet Plan for the. submitter to transfer claim files and to retrieve acknowledgements and claims status. reports We can also periodically retrieve claim files from and put acknowledgement. and initial claims status reports on an FTP server at the submitter s location. All BMC HealthNet Plan FTP directories have the following sub folders. Archive previously submitted files are kept here, Inbox new production files should be submitted here. Reports new and old acknowledgement and claims acceptance reports can. be downloaded here,Test all test files should be submitted here.
Some submitters may see an additional directory,835 ERAs can be retrieved here. This section details the testing procedures for anyone wishing to submit electronic. claims directly to BMC HealthNet Plan, Prior to implementing direct 837 EDI claims submission with the Plan testing must. be successfully completed The following series of tests will be run. Page 9 BMCHP 5010 EDI Claims Companion Guide v6 January 2016. Testing continued,Phase I Connection testing, The first phase of testing ensures the ability to exchange files securely Testing. involves exchanging test files dummy data through the chosen connection. mechanism e g FTP and encryption decryption programs e g PGP. Requirements, Submitter should have PGP or Secure FTP software installed prior to testing and. keys should be exchanged with BMCHP if necessary Once an FTP directory is. set up here at the Plan the host address username and password necessary for. FTP transmissions will be given to the submitter Submitter should also have FTP. software installed and proper settings in place,Test Goals.
Successful encryption and decryption of files if using PGP. Successful secure connection if using Secure FTP, Successful transmission of 837 files and reception of reports. Phase II Initial Content testing, The second phase of testing checks that the claim files are in acceptable form The. submitter is asked to send a file of 15 25 claims using real BMC HealthNet Plan. claims patient data comparison copies on paper or in print image format should. also be sent to the Plan if neither is possible we can do a system to system claims. comparison so that we can make sure everything you want to send is being translated. correctly in the 837 A file naming convention including some form of incremental. date stamp designation that will work with submitter s file production automation. processes will be discussed and tested,Please note that test claim. Page 5 BM CHP 5010 EDI l aims ompan i nGu de v 6 J uary 201 7 BMC HealthNet Plan accepts 837 Institutional and 837 Professional files written to the 5010 Errata specifications 005010X223A2 for 837I 005010X222A1 for 837P only 8 BMC HealthNet Plan can accept 25 total diagnosis codes for 837I UB 04 claims

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