EDI Instructions

HIPAA Compliant Codes

All the Health care EDI Transaction set should use only the following HIPAA Compliant Codes

• Physicians Current Procedure Terminology (CPT)
• Health Care Financing Administration Common Procedural Coding System (HCPCS)
• International Classification of Diseases Clinical Mod (ICD-9-CM) Diseases
• Provider Taxonomy Codes
• National Drug Code

*ICD-10 codes are not allowed prior to effective mandate date of October 1, 2014.

Diagnosis Codes

According to the 837P TR3, a transaction is not X12 compliant if decimal points are used in diagnosis codes. Therefore, should a diagnosis code contain a decimal point, BCBSGa will return a 999 to the  submitter indicating that the transaction has been rejected.

Address Information

P.O. mailboxes / Lock Boxes are not allowed in the Billing Provider loop. If submitted in the Billing Provider loop, then it will be returned to the submitter identifying which claim(s) have failed.

The Pay-to Address loop does support P.O. Box / Lock Box addresses. Therefore, if payment is expected to be remitted to a P.O. Box / Lock Box, submit the P.O. Box / Lock Box address.

Full 9-digit zip codes are required in the Billing Provider and Service Facility Location loops. If 5-digit zip codes are used in these loops, it  will be returned to the submitter identifying which claim(s) have failed

        

 

 

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Understanding EDI Structure

EDI Structure
Primary Levels are

1. Interchange Envelops
2. Functional Group
3. Transaction set

Data Element

A data element is equivalent to a field in a data dictionary. Data elements have a name, a data element number, a brief description, a data type, and a minimum and maximum length. For elements which represent codes, either a list of valid codes is included or a reference is included to a source outside of the X12 standard. Elements are separated by delimiters
 
Data Types

Data elements may have the following types:

N - Numeric with implied decimal point, signed.
Example: N2 indicates a numeric with two decimal places. 12.34 becomes 1234. N0 indicates in integer.

R - Decimal Number with explicit decimal point, signed.
Example: 12.34 represented in R format is 12.34. Starting with 4010, exponential notation is also supported.

ID - Identifier - A coded value, usually alphanumeric.

AN - String - alphanumeric.

DT - Date - YYMMDD. As of 4010, CCYYMMDD is also supported.

TM - Time - HHMM, with optional seconds and hundredths.

B - Binary - Any sequence of 8 bit bytes.

Composite Data Structure

A composite data structure consists of two or more simple data elements separated by a delimiter character known as the component data element separator. The individual component data elements in the composite may be designated as either mandatory or optional.

Segment

A segment is a logical grouping of data elements. A segment is equivalent to a record type. A segment is composed of one or more data elements or composite data structures, which are equivalent to the fields in a record. Segments start with a two or three character segment tag which identifies the segment, equivalent to a record type field. Data elements are separated by a delimiter character known as an element separator, and end with a different delimiter character known as the segment terminator.

Elements which are not assigned values in a particular instance of a segment are represented by consecutive delimiters, and such trailing delimiters are not transmitted. For example, if a segment XYX has five elements and in a particular transmission only the second has a value, it is represented as XYZ**123<CR>, where "*" is the element separator and <CR> is the segment terminator.

 

 

Delimiters

In an X12 message, the various delimiters are part of the syntax, dividing up the different elements of a message. The delimiters used in a message are defined in the interchange control header, the outermost layer enveloping the message.

For this reason, there is flexibility in the delimiters that are used. No suggested delimiters are recommended as part of the X12 standards, but the industry-specific implementation guides do have recommended delimiters.

The default delimiters  are:

Segment terminator
~ (tilde)

Data element separator
* (asterisk)

Subelement (component) separator
: (colon)

Repetition separator (version 4020 and later)
+ (plus sign)

 

Loop

Loop is a set of related segments in a Transaction Set. Segments are grouped together in this way to conveniently represent a block of related information. No formal Loops are defined, but several basic loop types, such as a Name/Address loop, appear with minor variations in many Transaction Sets. Different loops may be nested within each other, and loops may repeat up to the maximum loop occurrences specified within the Transaction Set.

Example for loop

1000A (Submitter) Loop

This loop contains submitter information.  A submitter is the entity that is sending the claims to the payer.  In most cases, this is the doctor or clinic name.

Example: NM1*41*2*DOCTORSOFFICE*****46*44444~

2010BA (Insured Patient) Loop

This loop contains the Patient (if the patient is the insured, otherwise Insured Person) Name, contract number, address, SSN (if used), and birthdate.

Example:

NM1*IL*1*DOE*JOHN*F***MI*ABC849559999~     ('MI' stands for member identification, followed by contract number)
N3*6022 VALLEY TRAIL~
N4*RUTH*MI*48883~
DMG*D8*19750101*M~                   ('DMG' stands for Demographic (Birth date) information.  Date format is CCYYMMDD)

Understanding EDI-Loops, Segments, and Elements

The best way to think of an EDI claim file is like a page in a book:

The Loops tell you the paragraph
The Segments tell you the sentence
The Elements tell you the word

All of this information together tells you the exact location of the problem.

Here's an example:

Let's say you received a rejection on a 5010 Professional claim, that states Loop 2300, Segment CLM05, Element 1. 
In EDI we would read this as Loop 2300, CLM05-1.

But what does it mean?  Let's break it down--Loop 2300--this is the Claim Information loop (all information relating to the claim, including place of service, admit/discharge dates, etc.  Okay, so we know the problem is in the Claim Information Loop.

Next is the Segment-CLM05.  The 5010 837P Implementation Guide (available from Washington Publishing Company) states
that CLM05 is for Health Care Service Location Information.

Finally, the Element-1.  Again, we consult our implementation guide--CLM05, Element 1, is for Facility Code Value, or Place of Service.  We may not know exactly what the problem is, but we know where to locate the problem in our claim file; and, since we know the field for this Loop/Segment/Element is Place of Service, we should be able to locate this in our software system.

        

 

 

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What is an EDI ?

EDI X12 (Electronic Data Interchange) is data format based on ASC X12 standards. It is used to exchange specific data between two or more trading partners. Term ‘trading partner’ may represent organization, group of organizations or some other entity. In most cases it is just organization or company.

EDI X12 is governed by standards released by ASC X12 (The Accredited Standards Committee). Each release contains set of message types like invoice, purchase order, health care claim, etc. Each message type has specific number assigned to it instead of name. For example: an invoice is 810, purchase order is 850 and health care claim is 837.

Every new release contains new version number. Version number examples: 4010, 4020, 4030, 5010, 5030, 6010, etc. Major releases
start with new first number. For example: 4010 is one of the major releases, so is 5010. However 4020 is minor release. Minor releases contain minor changes or improvements over major releases. At the time of this writing 5010 is most widely used release.

How EDI Works

Doctor diagnosis the patient and provide the treatment for the identified disease. Billing Team prepare the bill(claim) and the claim is transmitted into an EDI Document format called as 837 Health care claim. Then the EDI 837 Document securely transmitted to the insurance company via clearing house.

Then the Insurance company processes the claim which comes in the electronic format and provide the necessary reimbursement for the provider for the treatment given to the patient.
Why You Need EDI – the Benefits

• Lower costs
• Higher efficiency
• Improved accuracy
• Enhanced security
• Greater management information

        

 

 

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com. You can hire me as consultant for EMR/PMS Domain and Web development on EMR/PMS Product!

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