Electronic Remittance Advice
Version 3
UHIN Standard #68 Electronic Remittance Advice is compatible with all HIPAA requirements. Purpose: The purpose of Standard #68 is to detail the Standard transactions for the transmission of health care remittance advices in the state of Utah. The Standard may be adopted voluntarily prior to that date. Applicability: This Standard applies to all electronically exchanged remittance advice transactions for professional, institutional, and dental claims. Detail: 1. Standard Remittance Advice Transaction: The UHIN Standard for electronic remittance advice is the HIPAA 005010x221 implementation guide. See the Washington Publishing Company web site (http://www.wpc-edi.com) to download a copy of the implementation guides in Adobe Acrobat. 3. Adjustment Codes: Payers will use the 835 Group Codes and Claim Adjustment Reason codes in their 835 transmissions. The Medicare Remarks Code list will be used by all payers for remittance advice remarks to further explain generic remittance codes. See the national code list for those codes that require remark codes. The 835 Group and Standard Adjustment Reason codes are revised up to three times per year by the Code Maintenance Committee. The “most recent” version of these lists is defined to be the published lists as of 2 months after the most recent Code Maintenance Committee meeting. Currently the Code Maintenance Committee meets the first week in February, June, and October. Hence, the “most recent” version of the Adjustment Reason Code list which will be utilized by UHIN network members are those published in April, August, and December. See the Washington Publishing Company web site (http://www.wpc-edi.com) for details. The Remarks Code list is published at that same intervals as the code lists. The “most recent” version of the Remarks code list will be the one published on the Washington Publishing Company web site (http://www.wpc-edi.com) in April, August, and December. 4. Response Transaction: Provider translators will utilize the 999, Functional Acknowledgement, to confirm receipt of the 835 and to report any syntactical or semantic transmission errors. See UHIN Standard #73. 5. Provider-Assigned Claim Control Number: The standard for the Patient Control Number is 38 positions. Payers must return this value in the 835 for re-association of claim to payment. In the case where the provider/submitter does not submit a patient control number on either electronic or paper claims, payers will return a “0" in the 835 CLP01 when an 835 is used to return remittance advice. 6. Remits to a Central Office: 1 In cases where a single amount (check/EFT ) is being remitted to a central office, but separate 835's are being sent to individual providers (all of whom report to the central office), the BPR02 (Provider Payment Total) may be less than the total amount sent to the central office. In this case, the BPR02 will be the portion of the total (central office) amount, which would have gone to the provider if they were receiving individual payments rather than the central office receiving a single payment. In this case, the central office would use the check number/EFT number received in TRN02 (1-040) to track all proportional amounts indicated in the 835 received by the individual providers. This way, the BPR02 will balance with the 835.
1 EFT = electronic funds transfer.
UHIN STANDARDS COMMITTEE Standard #68
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7. The 277 Claim Acknowledgment Transaction: The 835 are used only to report on the final financial statement of claims/encounters, which have been accepted for adjudication. The 277CA transaction cannot be used to report financial information on claims/encounters (see UHIN Standard #XX for additional information on use of the 277CA). 8. Identifying the Plan The purpose of this item is to standardize how plan information is identified in the ASC X12 835 transaction. This item applies only when a provider is paid at a different rate by different plans under the same payer and the payer combines their plan payments into a single 835. If a payer has multiple plans but providers are paid at the same rate under all the plans, or if the plan issues separate 835s by plan, then this item does not apply. It is used when plan information impacts payment. To indicate which plan the payment is being made under, use “CE – “Class of Contract” in Loop 2100 REF01 of the 835. REF02 contains whatever code(s) have been deemed necessary to convey this information. Payers are free to develop whatever code(s)/text string they wish to convey this information. The payer is responsible for informing the provider what each code/text string in REF02 means. The expectation is that, payers will not customize these codes/test strings by provider. Payers should use the same identification for each plan/program/group which impacts payment within their organization. IMPLEMENTATION ISSUES: 1. Payers will educate providers on the advantages of the automatic posting of electronic remittance advice. 2. Contact the UHIN Standards Manager if an 835-code issue arises or needs to be requested. 3. The implementation date for this Standard is January 1, 2012.
History: (MM/DD/YY) ORIGINATION DATE APPROVAL DATE EFFECTIVE DATE * A = Amendment
Original
A* 1
A2
A3 03/02/09
A4
A5
A6
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