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					      HIPAA Transaction Standard Companion Guide
         For Availity® Health Information Network Users

Refers to the Technical Reports Type 3 Based on ASC
                          X12 version 005010X222A1

                  837 – Health Care Claim Professional

              Companion Guide Version Number: 1.0


                                             July 2011
                                     Disclaimer

Florida Health Care Plan, Inc. (FHCP) Companion Guide for EDI Transactions
(Technical Reports, Type 3 (TR3) provides guidelines in submitting electronic
batch transactions. Because the HIPAA ASC X12- TR3s require transmitters and
receivers to make certain determinations /elections (e.g., whether, or to what
extent, situational data elements apply), this Companion Guide documents those
determinations, elections, assumptions or data issues that are permitted to be
specific to FHCP business processes when implementing the HIPAA ASC X12
5010 TR3s.

This Companion Guide does not replace or cover all segments specified in the
HIPAA ASC X12 TR3s. It does not attempt to amend any of the requirements of
the TR3s, or impose any additional obligations on trading partners of FHCP that
are not permitted to be imposed by the HIPAA Standards for Electronic
Transactions. This Companion Guide provides information on FHCP specific
codes relevant to FHCP business processes and rules and situations that are
within the parameters of HIPAA. Readers of this Companion Guide should be
acquainted with the HIPAA ASC X12 TR3s, their structure, and content.

This Companion Guide provides supplemental information that exists between
FHCP and its trading partners. Trading partners should refer to their Trading
                                                       ®
Partner Agreement for guidelines pertaining to Availity LLC, legal conditions
surrounding the implementation of the electronic data interchange (EDI)
transactions and code sets. However, trading partners should refer to this
Companion Guide for Information on FHCP business rules or technical
requirements regarding the implementation of HIPAA-compliant EDI transactions
and code sets.

Nothing contained in this Companion Guide is intended to amend, revoke,
contradict or otherwise alter the terms and conditions of your applicable Trading
Partner Agreement. If there is an inconsistency between the terms of this
Companion Guide and the terms of your applicable Trading Partner Agreement,
the terms of the Trading Partner Agreement will govern. If there is an
inconsistency between the terms of this Companion Guide and any terms of the
TR3, the relevant TR3 will govern with respect to HIPAA edits, and this
Companion Guide will control with respect to business edits.




FHCP 837 Professional Companion Guide Version: 1.0                             2
                                                   Table of Contents


DISCLAIMER .................................................................................................................................. 2

I.       INTRODUCTION .................................................................................................................. 5

        What is HIPAA 5010?........................................................................................................... 5

        Purpose of the Technical Reports Type 3 Guides............................................................ 5

        How to Obtain Copies of the Technical Reports Type 3 Guides .................................... 5

        Purpose of this 837 Companion Guide ............................................................................. 5

        About Availity L.L.C. – Patients. Not Paperwork.® .......................................................... 6

        Registration with Availity.................................................................................................... 6

II.      ASC X12 TRANSACTIONS SUPPORTED .......................................................................... 6

III.     GENERAL INFORMATION .................................................................................................. 7

        EDI Technical Assistance ................................................................................................... 7

        Password Changes.............................................................................................................. 7

IV.      EDI PROCESSING AND ACKNOWLEDGEMENTS ........................................................... 7

        EDI Processing Hours ......................................................................................................... 7

        997 Functional Acknowledgement Transaction ............................................................... 7

V.       PAYER – SPECIFIC REQUIREMENTS ............................................................................... 8

        Common Definitions............................................................................................................ 8

VI.      CONTROL SEGMENTS & ENVELOPES ............................................................................ 9

        Global Information ............................................................................................................... 9

        Enveloping Information – 837 Professional Claim Submission (Outbound to Payer) 11

        Business Requirements.................................................................................................... 13

VII.     TIPS FOR SENDING COORDINATION OF BENEFITS INFORMATION ......................... 19

VIII.    TRANSACTIONAL TESTING PROCESSES ..................................................................... 20



FHCP 837 Professional Companion Guide Version: 1.0                                                                                           3
IX.   DIRECT CONNECT WITH FHCP....................................................................................... 20

X.    TRADING PARTNER AGREEMENT ................................................................................. 20




FHCP 837 Professional Companion Guide Version: 1.0                                                                    4
         837 Health Care Professional Claim
              Companion Guide (5010)

I.      Introduction


What is HIPAA 5010?

The Health Insurance Portability and Accountability Act (HIPAA) require that the
health care industry in the United States comply with the electronic data
interchange (EDI) standards as established by the secretary of Health and
Human Services. The ASC X12 005010X212 is the established standard for
Claim Status Inquiry and Response (276/277).



Purpose of the Technical Reports Type 3 Guides

The TR3’s, Technical Reports Type 3 Guide for the 837 Health Care Professional
Claim transaction specifies in detail the required formats. It contains
requirements for the use of specific segments and specific data elements within
segments, and was written for all health care providers and other submitters. It is
critical that your software vendor or IT staff review this document carefully and
follow its requirements to send HIPAA-compliant files to FHCP via your vendor.



How to Obtain Copies of the Technical Reports Type 3 Guides

TR3 Guides for ASC X12 005010X222A1 Health Care Professional Claim (837 –
P) and all other HIPAA standard transactions are available electronically at
http://www.wpc-edi.com.



Purpose of this 837 Companion Guide

This Companion Guide was created for FHCP trading partners to describe the
data content, business rules, and characteristics of the applicable transaction.

FHCP 837 Professional Companion Guide Version: 1.0                                 5
About Availity L.L.C. – Patients. Not Paperwork.®

Availity optimizes information exchange between multiple health care
stakeholders through a single, secure network. The Availity Health Information
Network encompasses administrative, financial, and clinical services, supporting
both real-time and batch EDI via the web and through business to business
(B2B) integration. For more information, including an online demonstration,
please visit www.availity.com or call 1-800-AVAILITY (282-4548).



Registration with Availity

In order to register, you’ll need:

1.      Basic information about your practice, including your Federal Tax
        ID/National Provider Identifier.

2.      Someone with the legal authority (typically an owner or senior partner) to
        sign agreements for your organization.

3.     An office manager or other employee who can oversee the Availity
       implementation and maintain user IDs and access.



II.     ASC X12 Transactions Supported


FHCP processes the following ASCX12 837 005010X222A1 HIPAA transactions
for Professional Claim Submissions




FHCP 837 Professional Companion Guide Version: 1.0                                   6
III.    General Information


EDI Technical Assistance

To request technical assistance from FHCP, please send an email to
edisupport@fhcp.com.

Note: For support of EDI transactions through               Availity,   please   visit
www.Availity.com or call 1-800-AVAILITY (282-4548).




Password Changes

If a password change is necessary, please contact the Availity Health Information
Network at 1-800-Availity or www.Availity.com.




IV.     EDI Processing and Acknowledgements

The purpose of this section is to outline FHCP processes for handling the initial
processing of incoming files and the electronic acknowledgment generation
process.



EDI Processing Hours

The 837 Health Care Professional Claim transaction files can be transmitted
seven days per week, 24 hours per day.


997 Functional Acknowledgement Transaction

If the file submission passes the ISA/IEA pre-screening above, it is then checked
for ASC X12 syntax and HIPAA compliance errors. When the compliance check
is complete, a 997 Acknowledgement will be sent to the trading partner informing
them if the file has been accepted or rejected. If multiple transaction sets (ST-SE)



FHCP 837 Professional Companion Guide Version: 1.0                                  7
are sent within a functional group (GSGE), the entire functional group (GS-GE)
will be rejected when an ASC X12 or HIPAA compliance error is found.


V.       Payer – Specific Requirements

The purpose of this section is to delineate specific data requirements where
multiple valid values are presented within the 5010 TR3.



Common Definitions

        Interchange control header (ISA06) Interchange Sender ID (Mailbox
         ID) – is individually assigned to each trading partner.

        Interchange control header (ISA08) Interchange Receiver ID – is the
         FHCPL tax ID, 593222484.

        Interchange control header (ISA15) Usage Indicator – defines whether
         the transaction is a test (T) or production (P).

        Functional Group Header (GS02) Application Sender’s code – is
         individually assigned to each trading partner.




FHCP 837 Professional Companion Guide Version: 1.0                               8
VI.      Control Segments & Envelopes


Global Information


      Loop ID – Segment             Reference                    Plan Requirement
        Description &               Description
        Element Name

All Transactions                                     FHCP requires a Trading Partner
                                                     Agreement to be on file with Availity
                                                     indicating all electronic transactions the
                                                     Trading Partner intends to send or
                                                     receive.


All Segments                                         Only loops, segments, and data elements
                                                     valid for the 837 HIPAA-AS TR3 Guides
                                                     ASC X12 005010X222 &
                                                     ASC X12 005010X222A1 will be used for
                                                     processing.


Acknowledgments –                                    997 is available immediately after
                                                     “depositing file”
FHCP acknowledgements are
created to communicate the
status of transactions. It is
imperative that they be retrieved
on a daily basis. One file could
result in multiple
acknowledgements.

ANSI X12:

-997– Functional
Acknowledgement


Negative Values                                      Submission of any negative values in the
                                                     837 transaction will not be processed or
                                                     forwarded.


Date fields                                          All dates submitted on an incoming 837
                                                     Health Care Professional Claim must be a
                                                     valid calendar date in the appropriate

FHCP 837 Professional Companion Guide Version: 1.0                                           9
      Loop ID – Segment             Reference                    Plan Requirement
        Description &               Description
        Element Name
                                                     format based on the respective HIPAA-AS
                                                     TR3 qualifier. Failure to do so may cause
                                                     processing delays or rejection.


Batch Transaction Processing                         Generally, Availity and FHCP Gateway
                                                     accept transmissions 24 hours a day, 7
                                                     days a week.


All transactions                                     Health Care Professional Claims
                                                     submitted with multiple patient events will
                                                     be split into separate transactions and
                                                     returned one at a time.


All transactions – B2B / EDI                         FHCP requests to remove “-“ (dashes)
                                                     from all Tax Ids, SSNs and Zip codes.


All transactions                                     FHCP requires that you do not submit any
                                                     special characters in any text fields.



Multiple Transmissions           All Segments        Any errors detected in a transaction set
                                                     will result in the entire transaction set
                                                     being rejected.


All transactions                 PRV03               FHCP requires Provider Taxonomy
                                                     Code to be submitted in PRV03.
2010AA – Billing Provider Loop
2310B – Rendering Provider
Loop




FHCP 837 Professional Companion Guide Version: 1.0                                         10
Enveloping Information – 837 Professional Claim Submission (Outbound to
Payer)


     Loop ID – Segment             Reference                     Plan Requirement
 Description & Element Name        Description


Interchange Control                    ISA           All transactions utilize delimiters from the
Header                                               following list: >,*,~,^,|,{ and : . Submitting
                                                     delimiters not supported within this list
                                                     may cause an interchange (transmission)
                                                     to be rejected.


Interchange Control                    ISA           Must submit Professional Claim data
Structure                                            using the basic character set as defined in
                                                     Appendix B of the ASC X12
                                                     005010X222 TR3. In addition to the basic
                                                     character set, you may choose to submit
                                                     lower case characters and the special
                                                     character (@) from the extended
                                                     character set. Any other characters
                                                     submitted from the extended character
                                                     set may cause the interchange
                                                     (transmission) to be rejected by the Plan.


Interchange Control                   ISA01          FHCP requires 00 in this field.
Header
Authorization Information
Qualifier


Interchange Control                   ISA02          FHCP requires 10 spaces in this field.
Header
Authorization Information


Interchange Control                   ISA03
Header                                               FHCP requires 00 in this field.
Security Information
Qualifier


Interchange Control                   ISA04          FHCP requires 10 spaces in this field.
Header
Security Information




FHCP 837 Professional Companion Guide Version: 1.0                                           11
     Loop ID – Segment             Reference                        Plan Requirement
 Description & Element Name        Description

Interchange Control                   ISA05          FHCP requires 01 in this field.
Header
Interchange ID Qualifier


Interchange Control                   ISA06          FHCP requires submission of your
Header                                               individually assigned FHCP sender
Interchange Sender ID                                mailbox number in this field.


Interchange Control                   ISA07          FHCP requires ZZ in this field.
Header
Interchange ID Qualifier


Interchange Control                   ISA08          FHCP will only accept the submission of
Header                                               FHCP tax ID number 593222484 in this
Interchange Receiver ID                              field.


Interchange Control                   ISA11          FHCP only accepts { as repetition
Header                                               separator for all transactions.
Repetition Separator
                                                     Submitting delimiters other than this may
                                                     cause an Interchange (transmission) to be
                                                     rejected.


Interchange Control                   ISA15          FHCP requires P in this field to indicate
Header                                               the data enclosed in this transaction is a
Interchange Usage                                    production file.
Indicator


Interchange Control                   ISA16          : Delimiter
Header
Component Element                                    ---------------------------------------
Separator`
                                                     FHCP requires the use of the above
                                                     delimiter to separate component data
                                                     elements within a composite data
                                                     structure.


Interchange Control                   GS - GE        FHCP will only process one transaction
Header                               ISA - IEA       type per GSGE (functional group).
Functional Group                                     However, we will process multiple ST’s
Header/Functional Group                              within one (1) GS segment as long as
Trailer                                              they are all the same transaction type.

FHCP 837 Professional Companion Guide Version: 1.0                                             12
     Loop ID – Segment             Reference                     Plan Requirement
 Description & Element Name        Description




Functional Group Header               GS01           HC– Health Care Claim – Professional
Functional Identifier Code
                                                     FHCP requires submission of the above
                                                     value in this field.


Functional Group Header               GS02           FHCP requires the submission of the
Application Sender's Code                            published Sender ID in this field.


Functional Group Header               GS03           593222484
Application Receiver's Code
                                                     FHCP requires the submission of the
                                                     above value in this field for 837
                                                     Professional Claim Submission, all others
                                                     may cause rejection.


Implementation                         ST03          Must contain 005010X222A1.
Convention Reference




Business Requirements


     Loop ID – Segment             Reference                     Plan Requirement
 Description & Element Name        Description


1000A - Submitter Primary             NM109          FHCP requires the submission of the
Identification Number                                Published Sender ID in this data
                                                     element.
Identification Code


1000A – Submitter EDI Contact        PER 02          Required when the contact name is
Information                                          different than the name contained in the
                                                     Submitter Name segment of this loop and
Submitter Contact Name                               it is the first iteration of the Submitter EDI
                                                     Contact Information Segment.



FHCP 837 Professional Companion Guide Version: 1.0                                           13
     Loop ID – Segment             Reference                        Plan Requirement
 Description & Element Name        Description


1000B – Receiver Name                 NM103          FHCP

Last Name or Organization                            ---------------------------------------
Name
                                                     FHCP requests submission of above
                                                     value in this field.


1000B – Receiver Name                 NM109          593222484

Receiver Primary                                     ---------------------------------------
Identification Number
                                                     FHCP requests submission of above
                                                     value in this field.


2000B – Subscriber                    SBR09          FHCP requires setting SBR09 to 16
Hierarchical Level                                   (Health Maintenance Organization
                                                     /Medicare Risk).
Claim Filing Indicator Code


2010BA - Subscriber Name              NM108          Member ID required and qualifier must be
                                                     MI in NM108 for FHCP.
Identification Code Qualifier         NM109
                                                     FHCP requires submission of the ID
Subscriber Primary Identifier                        number (#) in NM109 exactly as it
                                                     appears on the FHCP ID card without
                                                     using any embedded spaces (this
                                                     includes any out of state Blue ID’s
                                                     )including any applicable alpha prefix or
                                                     suffix.


2010BA - Subscriber                  DMG03           F – Female
Demographic Information
                                                     M – Male
Gender Code
                                                     ---------------------------------------
2010CA - Patient Demographic
Information                                          FHCP requires that either the “F” or “M”
                                                     gender code be submitted. If any other
Gender Code                                          gender code is submitted, it will cause a
                                                     reject.


2010BA – Subscriber Address             N3           FHCP requires submission of the
& City/ State/ Zip Code                              subscriber’s address.
                                        N4

FHCP 837 Professional Companion Guide Version: 1.0                                             14
     Loop ID – Segment             Reference                        Plan Requirement
 Description & Element Name        Description


2010BB – Payer Name                   NM103          FHCP

Payer Name                                           ---------------------------------------

                                                     FHCP requests submission of above
                                                     value in this field.


2010BB – Payer Name                   NM108          PI – Payer Identification

Qualifier                             NM109          59322 – Florida Health Care Plans ID

Professional Payer ID                                ---------------------------------------

                                                     FHCP requests submission of above
                                                     value in this field.


2010BB – Payer Name                   REF01          FHCP requests setting REF01 to G2 if
                                                     utilized.
Reference Identification
Qualifier

2300 Claim Information /              CLM02          The total claim charge amount must equal
                                                     the sum of all submitted line items. Failure
2400 Service Line Number              SV102          to do so will result in claim rejection.

Monetary Amount                                      Note: If the whole dollar amounts are sent
                                                     in monetary elements, do not include the
Line Item Charge Amount                              decimal or trailing zero (E.g. $30 = 30).

                                                     When indicating the dollars & cents, the
                                                     decimal must be indicated (E.g. $30.12 =
                                                     30.12).


2300 – Claim Information             CLM05-3         FHCP will accept applicable code(s)

Claim Frequency Type Code                            Note: When submitting the corrected
                                                     claim, the original Reference Number
                                                     (ICN/DCN) also known as the Original
                                                     Claim Number is required to be sent in
                                                     loop 2300 REF. (REF01= F8 qualifier for
                                                     Original Reference Number, REF02 =
                                                     Original Claim Number) .


2300 Claim Information                  HI           FHCP requires that you do not transmit
                                                     the decimal points in the diagnosis codes.

FHCP 837 Professional Companion Guide Version: 1.0                                             15
     Loop ID – Segment             Reference                     Plan Requirement
 Description & Element Name        Description

Health Care Code Information                         The decimal point is assumed.


2310A – Referring Provider            REF01          FHCP requests Referring Provider name
Name                                                 if applicable in this field.

Reference Identification
Qualifier


2310B – Rendering Provider            REF01          FHCP requests Rendering Provider Name
Name                                                 in this field.

Reference Identification
Qualifier


2310C Service Facility                NM101          Billing Requirements for Blue Medicare
Location                              NM108          Non- Participating Providers
                                      NM109
Entity Identifier Code                               Providers who do not participate in the
Identifier Code Qualifier                            applicable Medicare network for
Identification Code                                  the member, should bill as they would for
                                                     a Medicare member and file the claim to
                                                     FHCP. FHCP reimburses Medicare non-
                                                     participating providers the prevailing
                                                     Medicare rate (less the member’s cost
                                                     share) for the service area in which the
                                                     service is rendered for Medicare
                                                     members. Standard Medicare billing
                                                     requirements apply including the
                                                     following:

                                                     • Provider name and address
                                                     • Rendering zip code for professional
                                                     claims
                                                     • Rendering zip code in the value code
                                                     field for ambulance pick-up
                                                      • Weight and height, in proper format, in
                                                     the value code fields for dialysis Services.

                                                     NM101 – Use 77 qualifier to indicate
                                                     Service
                                                     Location.
                                                     NM108 - Use XX qualifier to indicate
                                                     National Provider Identifier.
                                                     NM109 – Submit your office’s NPI value




FHCP 837 Professional Companion Guide Version: 1.0                                         16
     Loop ID – Segment             Reference                        Plan Requirement
 Description & Element Name        Description



Service Facility Location              N403          N403 – Submit your office’s 9-digit zip
City/State/Zip                                       code
Postal Code




2310D – Service Facility              REF01          FHCP requests Service Facility Location
Location Name                                        Name in this field.

Reference Identification
Qualifier


2320 Other Subscriber                 SBR09          If MB is used in SBR09 to indicate
Information                                          Medicare Part B as the other payer, then
                                                     send F8
Claim Filing Indicator Code                          (Original Reference Number) in REF01
                                                     and Medicare ICN (Original Reference
                                                     Number)
                                                     in REF02.


2320 Outpatient Adjudication           MOA           FHCP requests that this information be
Information                                          provided to facilitate claims processing.


2330B Other Payer Name                NM108          FHCP requests the “PI” qualifier in this
                                                     field.


2400 – Service Line Number           SV101-1         HC
                                                     ---------------------------------------
Product/Service ID Qualifier
                                                     FHCP requests submission of above
                                                     value in this field as only HCPCS
                                                     Procedure codes are accepted by FHCP
                                                     at this time.


2400 Professional Service            SV101- 3        Please submit the appropriate modifiers in
                                                     priority order.
Procedure Modifier(s)                SV101- 4

                                     SV101-5

                                     SV101-6



FHCP 837 Professional Companion Guide Version: 1.0                                             17
     Loop ID – Segment             Reference                    Plan Requirement
 Description & Element Name        Description


2410 Drug Identification               LIN           DME Providers
                                       CTP
Drug Identification                                  LIN – NDC must be submitted
Drug Quantity
                                                     CTP – Quantity must be submitted.


2410 Drug Identification              LIN03          Must be eleven numeric digits in 5-4-2
                                                     format. Other characters are not allowed.
National Drug Code (NDC)


All loops with N403                                  FHCP requires submission of 9 digit
                                                     postal code.
Postal Code


Coordination of Benefits               2300          Total Claim Charge Amount (CLM02)
(COB) Balancing                        2400          should be equal to sum of the service line
                                                     charge amounts (sum of the SV102’s).




FHCP 837 Professional Companion Guide Version: 1.0                                         18
VII. Tips for Sending Coordination of Benefits
Information
When Florida Health Care Plans (FHCP) is secondary, please remember to
include coordination of benefits (COB) data on your claim as outlined below. All
HIPAA mandated fields are required. The business requirements and
corresponding 837 fields listed below are necessary to process COB information
on FHCP claims.


R =Required              837 Fields                       Business Requirement
S=Situational


       S         Loop 2320 CAS 01-19, as       Submission of other insurance payment information
                 needed                        requires claim adjustment group codes and
                                               associated monetary amounts. Please be sure to
                                               submit any differences between the paid and
                                               charge amounts in the CAS segments. FHCP
                                               requires the CAS segments and the AMT segments
                                               equal the charge amount.


       R         Loop 2320 AMT 01              When FHCP is secondary, submit the primary
                           AMT 02              insurer payment information to support correct
                                               processing of COB information.

                                               2320 AMT01 – D is required
                                               2320 AMT02 – Sum of all Line level Payment
                                               Amount minus any Claim Level Adjustment
                                               amounts must balance to Claim level Payment
                                               Amount.


       R         Loop 2430 CAS segments        When Medicare is primary and FHCP is secondary,
                 Loop 2430 SVD 02              FHCP requires:
                                               All line level adjustment reason codes & Payment
                                               amounts which must balance.




FHCP 837 Professional Companion Guide Version: 1.0                                      19
VIII.   Transactional Testing Processes

All trading partners, clearing houses should be certified via Availity. It is
recommended that the trading partner obtain HIPAA Certification from an
approved testing and certification third party vendor, prior to testing.


IX.     Direct Connect with FHCP
FHCP offers a Direct Connect alternative compared to traditional Clearinghouse
to receive the 837 transaction. Each Direct Connect option is unique per provider
and transactions are sent via a secured FTP. For questions regarding EDI
submission, testing, enrollment, or setup please contact FHCP EDI support at:
edisupport@fhcp.com or call 386-615-4090



X.      Trading Partner Agreement
Please contact Availity at 1-800-Availity or www. Availity.com for your Trading
Partner Agreement.




FHCP 837 Professional Companion Guide Version: 1.0                                20

				
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