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Little Rock, AR 72201 .... If necessary, Arkansas Medicaid can identify and reference all split claims from the original claim for certain purposes, such as ..... For Long Term Care Hospice claims, enter the nursing home facility's license number.
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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 | |1.2 |05/05/11|Toni Butler | |Update Version/Release/Industry | | | | | |Identifier 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’ | |1.6 |12/27/13|Christine |Loop 2300 |Add NTE | | | |Willems | | | |1.7 |10/06/15|Arlie Coffman|Loop 2300 |Revise these fields for ICD-10: | | | | | |HI01-4 Principal Procedure | | | | | |Information | | | | | |HI01-1 | | | | | |HI01-2 | | | | | |HI01-4 Other Procedure | | | | | |Information | | | | | |HI02-2 | | | | | |HI02-4 | | | | | |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



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

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 – |REF |REF01 |Value = 0B |334 | |Operating 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 |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 | | |transaction. Arkansas Medicaid still accepts the | | |minimum and maximum field lengths required by the | | |implementation guide for each element. | |Page |Page of the implementation guide on which the loop, | | |segment, or element is listed. |

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).

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).

Transaction 837, Health Care Claim: Institutional

|Loop ID – Loop Name |SEG |Element|Comments |Page | |ISA – Interchange Control |ISA |ISA01 |Value = 00 |C.4 | |Header | | | | | | | |ISA03 |Value = 00 |C.4 | | | |ISA05 |Value = ZZ |C.4 | | | |ISA06 |Value = Submitter ID |C.4 | | | |ISA07 |Value = 30 |C.5 | | | |ISA08 |Value = 716007869 |C.5 | | | |ISA15 |Value = P in production, T in test |C.6 | |GS – Functional Group |GS |GS02 |Value = Same as ISA06 |C.7 | |Header | | | | | | | |GS03 |Value = Same as ISA08 |C.7 | |BHT – Beginning of |BHT |BHT03 |Arkansas Medicaid’s translator requires the BHT03 |69 | |Hierarchical Transaction | | |field. BHT03 must be a unique number per file. The | | | | | |translator rejects files that do not meet this | | | | | |requirement. | | |Loop 1000A – Submitter |NM1 |NM103 |If NM102 = 1, Length = 15 |72 | |Name | | |If NM102 = 2, Length = 30 | | | | |NM104 |If NM102 = 1, Length = 10 |72 | | | |NM109 |Length = 8 |72 | | | | |Value = Submitter ID | | |Loop 1000B – Receiver Name|NM1 |NM109 |Value = 716007869 |77 | |Loop 2000A – Billing |PRV |PRV01 |BI = Billing provider |80 | |Pay-to Provider Specialty | | |Required if billing provider uses a taxonomy code to| | |Information | | |identify itself | | | | |PRV02 |Value = PXC |80 | | | |PRV03 |Length = 10 bytes |80 | | | | |Value = Taxonomy code | | |Loop 2010AA – Billing | | |Arkansas Medicaid only maps the 2010AA Billing | | |Provider Name | | |Provider information. 2010AB Pay-To Provider | | | | | |information is not used. For typical providers, enter| | | | | |NPI in NM109. For atypical providers, enter the | | | | | |Medicaid Provider ID in Loop 2010BB REF02. | | | | |NM108 |Value = XX (National Provider Identifier) |86 | | | |NM109 |Length = 10 |86 | |Loop 2010BA – Subscriber |NM1 |NM102 |Value = 1 |113 | |Name | | | | | | | |NM103 |Length = 2 |113 | | | |NM104 |Length = 1 |113 | | | |NM108 |Value = MI |113 | | | |NM109 |Length = 10 |114 | | | | |Value = Recipient’s Medicaid ID Number | | |Loop 2010BB – Billing |REF |REF01 |Value = G2 (Medicaid Provider number) |129 | |Provider Secondary | | | | | |Identification | | | | | | | |REF02 |Length = 9 |130 | |Loop 2000C – Patient | | |Arkansas Medicaid does not use the Dependent Loop. |131 | |Hierarchical Level | | | | | |Loop 2300 – Claim |CLM |CLM01 |Length = 20 |144 | |Information | | |This value will be returned on the TRN segment in | | | | | |Loop 2200D of the unsolicited 277. | | | | |CLM02 |Length = 8 |145 | | | |CLM05-3|Arkansas Medicaid only processes the following |145 | | | | |values: | | | | | |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 to be entered, but Arkansas Medicaid will use | | | | | |only the first two bytes (HH). | | | |DTP |DTP03 |DTP 01 = 435 and DTP02 = DT |151 | | | | |Admission Date/Hour | | | | | |Length = 12 (Date = first 8 bytes, Hour = last 2 | | | | | |bytes) | | | | | |Note: The implementation guide requires the format | | | | | |CCYYMMDDHHMM to be entered, but Arkansas Medicaid | | | | | |will use only the first ten bytes (CCYYMMDDHH). | | | |NTE |NTE01 |ADD | | | | |NTE02 |3599 Incarcerated Indicator | | | | | |Note: This value is only returned when it is | | | | | |indicated that the beneficiary is incarcerated. | | | |PWK | |Arkansas Medicaid maps Claim Supplemental information|154 | | | | |at the 2300 (Claim-level) only. Service Line | | | | | |information from 2400 is not mapped. | | | | |PWK06 |Length = 20 |157 | | |REF |REF02 |REF01 = D9 |170 | | | | |Claim ID for Clearinghouses and Other Transmission | | | | | |Intermediaries | | | | | |Length = 30 | | | |REF |REF02 |REF01 = F8 |166 | | | | |Original Reference Number | | | | | |Length = 13 | | | |REF |REF02 |REF01 = G1 |164 | | | | |Prior Authorization Number | | | | | |Length = 10 | | | |REF |REF02 |REF01 = EA |173 | | | | |Medical Record Number | | | | | |Length = 15 | | | |HI |HI01-2 |Principal, Admitting, and E-Code Diagnosis |185 | | | | |Information | | | | | |Length = 7 | | | | |HI02-2 |If HI02-1 = BJ, Length = 7 |188 | | | |HI03-2 |If HI03-1 = BN, Length = 7 |194 | | |HI |HI01-2 |Other Diagnosis Information |221 | | | | |Length = 7 | | | | |HI02-2 |Length = 7 |222 | | | |HI03-2 |Length = 7 |224 | | | |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 | | |HI |HI01-4 |Principal Procedure Information |239 | | | | |Length = 7 | | | | |HI01-1 |Length = 8 |240 | | |HI |HI01-2 |Code list qualifier |243 | | | | |Value = BQ or BBQ | | | | |HI01-4 |Other Procedure Information |243 | | | | |Length = 8 | | | | |HI02-2 |Length = 7 |243 | | | |HI02-4 |Length = 8 |244 | | | |HI03-2 |Length = 7 |245 | | | |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 | | | | | |Length = 2 | | | | | |The translator checks all 12 occurrences and maps | | | | | |only occurrence span code M0 and the corresponding | | | | | |span dates. | | | |HI |HI01-2 |HI01-1 = BH |271 | | | | |Occurrence Information | | | | | |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 | | | |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 |HI01-2 |HI01-1 = BE |284 | | | | |Value Information | | | | | |Length = 2 | | | | |HI01-5 |Length = 8 |285 | | | |HI02-2 |Length = 2 |285 | | | |HI02-5 |Length = 8 |285 | | | |HI03-2 |Length = 2 |286 | | | |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 | | |HI |HI01-2 |HI01-1 = BG |294 | | | | |Condition Information | | | | | |Length = 2 | | | | |HI02-2 |Length = 2 |295 | | | |HI03-2 |Length = 2 |296 | | | |HI04-2 |Length = 2 |297 | | | |HI05-2 |Length = 2 |297 | |Loop 2310A – Attending | | |Arkansas Medicaid maps Attending Physician | | |Physician Name | | |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. | | | |NM1 |NM108 |Value = XX (National Provider Identifier) |321 | | | |NM109 |Length = 10 |321 | | |REF |REF01 |Value = 0B (State License Number) |324 | | | |REF02 |Length = 9 |325 | | | | |Enter the physician’s license number. If the | | | | | |physician is non-participating (does not participate | | | | | |in the Arkansas Medicaid program), enter NP + license| | | | | |number. | | |Loop 2310B – Operating | | |Arkansas Medicaid maps Operating Physician | | |Physician Name | | |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. | | | |NM1 |NM108 |Value = XX (National Provider Identifier) |328 | | | |NM109 |Length = 10 |328 | | |REF |REF01 |Value = 0B (State License Number) |329 | | | |REF02 |Length = 9 |330 | |Loop 2310E – Service |REF |REF01 |Value = LU (location number) or 0B (State license |347 | |Facility Location Name | | |number) | | | | | |For Long Term Care Hospice claims, enter the nursing | | | | | |home facility’s license number. | | | | |REF02 |Length = 9 |348 | |Loop 2310F – Referring | | |Arkansas Medicaid maps Referring Provider information| | |Provider Name | | |at the 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. | | | |NM1 |NM108 |Value = XX (National Provider Identifier) |351 | | | |NM109 |Length = 10 |351 | | |REF |REF01 |Value = G2 (Medicaid Provider ID) | | | | |REF02 |Length = 9 | | |Loop 2320 – Other | | |Arkansas Medicaid maps only 2 occurrences of the 2320| | |Subscriber Information | | |loop. | | | |CAS |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 | | | |CAS12 |If CAS11 = 1, 2, or 66, Length = 8 |362 | | | |CAS15 |If CAS14 = 1, 2, or 66, Length = 8 |362 | | | |CAS18 |If CAS17 = 1, 2, or 66, Length = 8 |363 | | |AMT |AMT02 |AMT01 = D |364 | | | | |COB Payer Paid Amount | | | | | |Length = 8 | | | |AMT |AMT02 |AMT01 = A8 |366 | | | | |Coordination of Benefits (COB) Total Non-Covered | | | | | |Amount | | | | | |Length = 8 | | | |MIA |MIA01 |Length = 3 |369 | |Loop 2330A – Other |NM1 |NM102 |Value = 1 |378 | |Subscriber Name | | | | | | | |NM103 |Length = 15 |378 | | | |NM104 |Length = 10 |378 | | | |NM109 |If NM108 = MI, Length = 20 |379 | | |N3 |N301 |Length = 25 |380 | | | |N302 |Length = 25 |380 | | |N4 |N401 |Length = 18 |381 | | | |N403 |Length = 9 |382 | |Loop 2330B – Other Payer |NM1 |NM103 |Length = 30 |385 | |Name | | | | | | | |NM109 |If NM108 = PI, Length = 4 |385 | | |N3 |N301 |Length = 25 |386 | | | |N302 |Length = 25 |386 | | |N4 |N401 |Length = 18 |387 | | | |N403 |Length = 9 |388 | | |DTP |DTP03 |DTP01 = 573 (Claim Check or Remittance Date) |389 | | | | |Length = 8 | | | |REF |REF01 |REF01 = F8(Other Payer Claim Control Number) |395 | | | |REF02 |Length = 13 |395 | |Loop 2400 – Service Line |SV2 |SV201 |Length = 4 |424 | |Number | | | | | | | |SV202-2|If SV202-1 = HC, Length = 5 |425 | | | |SV203 |Length = 8 |427 | | | |SV205 |If SV204 = DA or UN, Length = 5 |428 | | | | |The translator drops decimal values. | | | | |SV206 |Length = 8 |428 | |Loop 2400 – DTP Service | |DTP01 |Value = 472 |434 | |Line Date (Nursing Home | | | | | |Requirement) | | | | | | | |DTP02 |RD8 |434 | | | |DTP03 |Length = 8 for each date (from DOS/to DOS) |434 | | Loop 2410 – Drug | | | Arkansas Medicaid maps only 5 occurrences of the |450 | |Identification | | |2410. | | | |LIN |LIN03 | Length = 11 |451 | | |CTP |CTP04 | Length = 5 |452 | | |REF |REF01 |VALUE = VY (Link Sequence Number) or XZ (Pharmacy |454 | | | | |Prescription Number) | | | | |REF02 |Length = 12 |455 | |Loop 2420A– Operating | | |Arkansas Medicaid maps Operating Physician |456 | |Physician Name | | |information at the 2310B (Claim-level) only. Service | | | | | |Line information from 2420B is not mapped. | | |Loop 2420D– Referring | | |Arkansas Medicaid maps Referring Provider information|471 | |Provider Name | | |at the 2310C (Claim-level) only. Service Line | | | | | |information from 2420C is not mapped. | | |Loop 2430 – Line | |SVD02 |Service Line Paid Amount |477 | |Adjudication Information | | | | |

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