Companion Guide 837 Health care claim: Institutional X005010X223A2

DXC Technology Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, AR 72201 501.374.6608 Modification log

Rev # Date Author Section Nature of Change 1.0 03/03/11 Draft 1.1 04/29/11 Toni Butler Loop 2320 Revised COB element AMT-02 Update Version/Release/Industry Identifier 1.2 05/05/11 Toni Butler Code 1.3 10/31/11 Toni Butler Loop 2410 Revise REF02 field_ Length = 12 1.4 10/31/11 Toni Butler Release 1.5 07/27/12 Toni Butler Loop 2310E Add REF01 element value ‘0B’ Christine 1.6 12/27/13 Loop 2300 Add NTE Willems Revise these fields for ICD-10: HI01-4 Principal Procedure Information HI01-1 HI01-2 HI01-4 Other Procedure Information HI02-2 HI02-4 1.7 10/06/15 Arlie Coffman Loop 2300 HI03-2 HI03-4 HI04-2 HI04-4 HI05-2 HI05-4 HI01-2 Contents

This guide...... 1 Scope...... 1 Updates...... 1 Contact...... 1 Links...... 1 Conventions...... 2 Special considerations...... 3 Batch Size...... 3 Electronic splitting of 837 claim transactions...... 3 837I LTC claim filing requirements...... 3 837 Institutional claims with more than 180 details...... 4 Supplemental data file for rejected claims...... 4 Transaction 837, Health Care Claim: Institutional...... 5

10/31/11 ii This guide Scope

This document is a companion guide to the ASC X12 Standards for Electronic Data Interchange Technical Report Type 3, Health Care Claim: Institutional, ASC X12N 837 (005010X223A2). It is intended for vendors that design software or systems for submitting health care transactions electronically to Arkansas Medicaid. This document supplements, but does not supersede, requirements outlined in the ASC X12N implementation guide.

The Health Insurance Portability and Accountability Act (HIPAA) requires Arkansas Medicaid and other covered entities to comply with the electronic data interchange standards for health care as established by the Secretary of Health and Human Services. The ASC X12N implementation guides were established as the standards of compliance. This companion guide provides the supplemental requirements specific to Arkansas Medicaid, as permitted within the 837 transaction sets.

Arkansas Medicaid follows the implementation guide for placement of the National Provider Identifier (NPI) for all transactions.

To develop and test a system for Arkansas Medicaid 837 transactions, follow both the 837 implementation guide and this companion guide. Updates

Changes to this guide are published on the Arkansas Medicaid website: www.medicaid.state.ar.us. Contact

See the Arkansas Medicaid website for contact information: www.medicaid.state.ar.us. Links

 HIPAA Implementation Guides: www.wedi-pc.com  Other Arkansas Medicaid companion guides: www.medicaid.state.ar.us

10/31/11 3 Conventions

Most of the companion guide is in table format (see example below). Only loops, elements, or segments with clarifications or comments are listed. For further information, please see the implementation guide for each transaction.

Loop ID – Loop Name SEG Element Comments Page Loop 2310B – Operating REF01 Value = 0B 334 REF Physician Name REF02 Length = 9 334

The table lists the following information:

Loop ID – Loop Name Loop, header, or trailer.

SEG Segment ID.

Element Element ID. Always incorporates the segment ID.

Comments or clarifications for Arkansas Medicaid. Values, data length, and repeats are also listed here. Clarifications in field length only indicate what Arkansas Medicaid uses or returns to process the Comments transaction. Arkansas Medicaid still accepts the minimum and maximum field lengths required by the implementation guide for each element.

Page of the implementation guide on which the loop, segment, or Page element is listed.

10/31/11 4 Special considerations Batch size

For faster claims processing, we strongly recommend batches contain a maximum of 2,000 claims per batch. Electronic splitting of 837 claim transactions

If a submitted claim has a higher detail count than Arkansas Medicaid can process, the details are split into multiple claims. See the table below for detail count limits for each of the 837 Institutional transactions.

Claim type Detail count limit 837I Inpatient 28 837I LTC* 28 837I Outpatient 20 *Long Term Care

Each split claim receives a unique Internal Control Number (ICN). Each ICN increases by one, starting from the original claim’s ICN. Once split, a claim will not be brought together again for processing. However, these split claims are linked within the system. This allows for full claim status request/response (276/277) capability. If necessary, Arkansas Medicaid can identify and reference all split claims from the original claim for certain purposes, such as research.

If any split claim suspends or denies at the header level, some or all of the other split claims associated with the original claim may suspend or deny. If a split claim suspends or denies at the detail level, only that split claim is affected; all other split claims associated with the original claim will not automatically be suspended or denied.

If a claim reversal transaction is submitted for a split claim, only the individual ICN submitted on the reversal transaction will be reversed. In order to reverse the entire original claim, an individual reversal transaction must be submitted for each ICN that resulted when the original claim was split.

A separate 835 is created for each split claim. The 835 does not link to the original claim. 837I LTC claim filing requirements

A single LTC claim cannot contain services that span more than a single month. Additional requirements related to this topic can be found in the “Census report data requirements” document located on the Arkansas Medicaid website under HIPAA Companion Guides (www.medicaid.state.ar.us).

4/19/12 5 837 Institutional claims with more than 180 details

If a submitted 837I transaction contains more than 180 details, Arkansas Medicaid receives the transaction electronically but processes it manually. Arkansas Medicaid returns a generic 277 response for each successfully received 837I. This indicates that the claim was received for processing. However, 837I claims with more than 180 details will not have any initial edits or audits.

Arkansas Medicaid creates a report of all claims submitted with more than 180 details. Each claim is then evaluated individually. Depending on the evaluation, one of the following actions is taken:

 Arkansas Medicaid notifies the submitter to resubmit the claim with 180 details or less.  The claim is split into smaller claims. Arkansas Medicaid enters the smaller claims manually, which can potentially delay payment. A separate 835 transaction is created for each smaller claim instead of the overall claim. Supplemental data file for rejected claims

When the Arkansas Medicaid system rejects a claim, a supplemental data file is returned in addition to the standard 277 response. The supplemental data file contains detailed error codes to assist with determining the reason for the claim’s rejection.

For additional details on this topic, please refer to the “Supplemental data file for rejected transactions” document located on the Arkansas Medicaid website under HIPAA Companion Guides (www.medicaid.state.ar.us).

4/19/12 6 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page ISA01 Value = 00 C.4 ISA03 Value = 00 C.4 ISA05 Value = ZZ C.4 ISA – Interchange Control ISA ISA06 Value = Submitter ID C.4 Header ISA07 Value = 30 C.5 ISA08 Value = 716007869 C.5 ISA15 Value = P in production, T in test C.6 GS02 Value = Same as ISA06 C.7 GS – Functional Group Header GS GS03 Value = Same as ISA08 C.7 Arkansas Medicaid’s translator requires the BHT03 field. BHT03 BHT – Beginning of Hierarchical BHT BHT03 must be a unique number per file. The translator rejects files that do 69 Transaction not meet this requirement. If NM102 = 1, Length = 15 NM103 72 If NM102 = 2, Length = 30 Loop 1000A – Submitter Name NM1 NM104 If NM102 = 1, Length = 10 72 Length = 8 NM109 72 Value = Submitter ID Loop 1000B – Receiver Name NM1 NM109 Value = 716007869 77 BI = Billing provider PRV01 80 Required if billing provider uses a taxonomy code to identify itself Loop 2000A – Billing Pay-to PRV PRV02 Value = PXC 80 Provider Specialty Information Length = 10 bytes PRV03 80 Value = Taxonomy code Loop 2010AA – Billing Provider Arkansas Medicaid only maps the 2010AA Billing Provider Name information. 2010AB Pay-To Provider information is not used. For typical providers, enter NPI in NM109. For atypical providers, enter

10/06/15 7 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page the Medicaid Provider ID in Loop 2010BB REF02. NM108 Value = XX (National Provider Identifier) 86 NM109 Length = 10 86 NM102 Value = 1 113 NM103 Length = 2 113 Loop 2010BA – Subscriber NM104 Length = 1 113 NM1 Name NM108 Value = MI 113 Length = 10 NM109 114 Value = Recipient’s Medicaid ID Number Loop 2010BB – Billing Provider REF REF01 Value = G2 (Medicaid Provider number) 129 Secondary Identification REF02 Length = 9 130 Loop 2000C – Patient Arkansas Medicaid does not use the Dependent Loop. 131 Hierarchical Level Loop 2300 – Claim Information CLM Length = 20 CLM01 This value will be returned on the TRN segment in Loop 2200D of 144 the unsolicited 277. CLM02 Length = 8 145 CLM05- Arkansas Medicaid only processes the following values: 145 3 1 – ADMIT THRU DISCHARGE CLAIM 2 – INTERIM BILLING – FIRST CLAIM 3 – INTERIM BILLING – CONTINUING CLAIM 4 – INTERIM BILLING – LAST CLAIM 7 – REPLACEMENT - REPLACEMENT OF PRIOR CLAIM 8 – VOID PRIOR CLAIM Other values will be rejected. DTP DTP03 DTP01 = 096 149 Discharge Hour Length = 4 Note: The implementation guide requires the format HHMM

10/06/15 8 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page to be entered, but Arkansas Medicaid will use only the first two bytes (HH).

DTP 01 = 435 and DTP02 = DT Admission Date/Hour Length = 12 (Date = first 8 bytes, Hour = last 2 bytes) DTP DTP03 Note: The implementation guide requires the format 151 CCYYMMDDHHMM to be entered, but Arkansas Medicaid will use only the first ten bytes (CCYYMMDDHH).

NTE01 ADD NTE02 NTE 3599 Incarcerated Indicator Note: This value is only returned when it is indicated that the beneficiary is incarcerated. Arkansas Medicaid maps Claim Supplemental information at the 2300 (Claim-level) only. Service Line information from 2400 is not 154 PWK mapped. PWK06 Length = 20 157 REF01 = D9 REF REF02 Claim ID for Clearinghouses and Other Transmission Intermediaries 170 Length = 30 REF01 = F8 REF REF02 Original Reference Number 166 Length = 13 REF01 = G1 REF REF02 Prior Authorization Number 164 Length = 10 REF01 = EA REF REF02 Medical Record Number 173 Length = 15 HI Principal, Admitting, and E-Code Diagnosis Information HI01-2 185 Length = 7 HI02-2 If HI02-1 = BJ, Length = 7 188

10/06/15 9 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page HI03-2 If HI03-1 = BN, Length = 7 194 Other Diagnosis Information HI01-2 221 Length = 7 HI02-2 Length = 7 222 HI03-2 Length = 7 224 HI HI04-2 Length = 7 225 HI06-2 Length = 7 227 HI07-2 Length = 7 228 HI08-2 Length = 7 230 HI01-2 Length = 7 231 Principal Procedure Information HI01-4 239 HI Length = 7 HI01-1 Length = 8 240 Code list qualifier HI01-2 243 Value = BQ or BBQ Other Procedure Information HI01-4 243 Length = 8 HI02-2 Length = 7 243 HI02-4 Length = 8 244 HI03-2 Length = 7 245 HI HI03-4 Length = 8 245 HI04-2 Length = 7 246 HI04-4 Length = 8 247 HI05-2 Length = 7 247 HI05-4 Length = 8 248 HI01-2 Length = 7 248 HI HI01-1 = BI 258 Occurrence Span Information

10/06/15 10 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page Length = 2 The translator checks all 12 occurrences and maps only occurrence span code M0 and the corresponding span dates. HI01-1 = BH HI01-2 Occurrence Information 271 Length = 2 HI01-4 Length = 8 272 HI02-2 Length = 2 272 HI02-4 Length = 8 273 HI03-2 Length = 2 273 HI03-4 Length = 8 274 HI04-2 Length = 2 274 HI HI04-4 Length = 8 275 HI05-2 Length = 2 275 HI05-4 Length = 8 276 HI06-2 Length = 2 276 HI06-4 Length = 8 277 HI07-2 Length = 2 277 HI07-4 Length = 8 278 HI08-2 Length = 2 278 HI08-4 Length = 8 279 HI HI01-1 = BE HI01-2 Value Information 284 Length = 2 HI01-5 Length = 8 285 HI02-2 Length = 2 285 HI02-5 Length = 8 285 HI03-2 Length = 2 286

10/06/15 11 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page HI03-5 Length = 8 286 HI04-2 Length = 2 287 HI04-5 Length = 8 287 HI05-2 Length = 2 288 HI05-5 Length = 8 288 HI06-2 Length = 2 288 HI06-5 Length = 8 288 HI07-2 Length = 2 289 HI07-5 Length = 8 289 HI08-2 Length = 2 290 HI08-5 Length = 8 290 HI09-2 Length = 2 291 HI09-5 Length = 8 291 HI10-2 Length = 2 291 HI10-5 Length = 8 291 HI11-2 Length = 2 292 HI11-5 Length = 8 292 H12-2 Length = 2 293 H12-5 Length = 8 293 HI01-1 = BG HI01-2 Condition Information 294 Length = 2 HI HI02-2 Length = 2 295 HI03-2 Length = 2 296 HI04-2 Length = 2 297 HI05-2 Length = 2 297

10/06/15 12 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page Arkansas Medicaid maps Attending Physician information at the 2310A (Claim-level) only. Service Line information from 2420A is not mapped. For typical providers, enter NPI in NM109. For atypical providers, enter the State License Number in REF02. NM108 Value = XX (National Provider Identifier) 321 Loop 2310A – Attending NM1 NM109 Length = 10 321 Physician Name REF01 Value = 0B (State License Number) 324 Length = 9 REF Enter the physician’s license number. If the physician is non- REF02 325 participating (does not participate in the Arkansas Medicaid program), enter NP + license number. Arkansas Medicaid maps Operating Physician information at the 2310B (Claim-level) only. Service Line information from 2420B is not mapped. For typical providers, enter NPI in NM109. For atypical providers, enter the State License Number in REF02. Loop 2310B – Operating NM108 Value = XX (National Provider Identifier) 328 Physician Name NM1 NM109 Length = 10 328 REF01 Value = 0B (State License Number) 329 REF REF02 Length = 9 330 Value = LU (location number) or 0B (State license number) Loop 2310E – Service Facility REF REF01 For Long Term Care Hospice claims, enter the nursing home 347 Location Name facility’s license number. REF02 Length = 9 348 Loop 2310F – Referring Arkansas Medicaid maps Referring Provider information at the Provider Name 2310F (Claim-level) only. Service Line information from 2420C is not mapped. For typical providers, enter NPI in NM109. For atypical providers, enter the Medicaid Provider ID in REF02. NM108 Value = XX (National Provider Identifier) 351 NM1 NM109 Length = 10 351 REF REF01 Value = G2 (Medicaid Provider ID)

10/06/15 13 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page REF02 Length = 9 Arkansas Medicaid maps only 2 occurrences of the 2320 loop. CAS03 If CAS02 = 1, 2, or 66, Length = 8 360 CAS06 If CAS05 = 1, 2, or 66, Length = 8 360 CAS09 If CAS08 = 1, 2, or 66, Length = 8 361 CAS CAS12 If CAS11 = 1, 2, or 66, Length = 8 362 CAS15 If CAS14 = 1, 2, or 66, Length = 8 362 Loop 2320 – Other Subscriber CAS18 If CAS17 = 1, 2, or 66, Length = 8 363 Information AMT01 = D AMT AMT02 COB Payer Paid Amount 364 Length = 8 AMT01 = A8 AMT AMT02 Coordination of Benefits (COB) Total Non-Covered Amount 366 Length = 8 MIA MIA01 Length = 3 369 NM102 Value = 1 378 NM103 Length = 15 378 NM1 NM104 Length = 10 378 Loop 2330A – Other Subscriber NM109 If NM108 = MI, Length = 20 379 Name N301 Length = 25 380 N3 N302 Length = 25 380 N401 Length = 18 381 N4 N403 Length = 9 382 Loop 2330B – Other Payer NM103 Length = 30 385 NM1 Name NM109 If NM108 = PI, Length = 4 385 N3 N301 Length = 25 386 N302 Length = 25 386

10/06/15 14 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

Loop ID – Loop Name SEG Element Comments Page N401 Length = 18 387 N4 N403 Length = 9 388 DTP01 = 573 (Claim Check or Remittance Date) DTP DTP03 389 Length = 8 REF01 REF01 = F8(Other Payer Claim Control Number) 395 REF REF02 Length = 13 395 SV201 Length = 4 424 SV202-2 If SV202-1 = HC, Length = 5 425 Loop 2400 – Service Line SV203 Length = 8 427 SV2 Number If SV204 = DA or UN, Length = 5 SV205 428 The translator drops decimal values. SV206 Length = 8 428 Loop 2400 – DTP Service Line DTP01 Value = 472 434 Date (Nursing Home DTP02 RD8 434 Requirement) DTP03 Length = 8 for each date (from DOS/to DOS) 434 Arkansas Medicaid maps only 5 occurrences of the 2410. 450 LIN LIN03 Length = 11 451 CTP CTP04 Length = 5 452 Loop 2410 – Drug Identification VALUE = VY (Link Sequence Number) or XZ (Pharmacy REF REF01 454 Prescription Number) REF02 Length = 12 455 Arkansas Medicaid maps Operating Physician information at the Loop 2420A– Operating 2310B (Claim-level) only. Service Line information from 2420B is not 456 Physician Name mapped. Arkansas Medicaid maps Referring Provider information at the Loop 2420D– Referring Provider 2310C (Claim-level) only. Service Line information from 2420C is not 471 Name mapped. Loop 2430 – Line Adjudication SVD02 Service Line Paid Amount 477 Information

10/06/15 15 Arkansas Medicaid Transaction 837, Health Care Claim: Institutional

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