HIPAA/Necessary EDI ID’s data you need to get from the Payer.

With version TPS 4.2.05 we support only the new HIPAA release 004010X098A1.

Before you start HIPAA – electronic billing you will need some EDI ID’s (Electronic Data Interchange) data (see the table below). This information is obtained from the Carrier (Payoy)

1. In the first light blue column you can see who should provide the EDI data: Payer (Carrier) or you (Provider). Note: Payer* means that you may have this data already.

2. In the second yellow column you can see the names of the data elements used in "ASC X12N INSURANCE SUBCOMMITTEE 004010X098 837 IMPLEMENTATION GUIDE HEALTH CARE CLAIM: PROFESSIONAL". This column is divided to 2 sub-columns:
a) Data element name.
b) Data element Loop/Segment-Position, in other words physical coordinates in 837 format (blue letters).

3. In the third light green column you can see the names of the data elements as they appear in TPS2000.

This table allows you to talk knowledgeably with your carrier representative. Your carrier will only recognize the field or segment names that appear in the second yellow column. Using this table, you may easily translate the field you recognize (i.e. Carrier / EDI Mailbox) to the name that they recognize (i.e. ISA-08). During our experience while testing the 837 file with Medicare in different states, we spent a lot of time trying to get this specific data. The problem is that different Payers use different names for the data elements you need, but ONLY the Data element Loop/Segment-Position (yellow sub-column) unambiguously determines what exact data is truly needed.

We strongly recommend that you refer the Payer to our website or send that table in MS Word format (click here) by email or print and fax it to the Payer.

If you signed an agreement with the Payer and received some data from them, but are having a problem filling in the table, you can contact the Payer and ask them to help you.

Table1. EDI ID’s data required by HIPAA ANSI X12 standard.

Comments.

1. Interchange ID qualifier. Usually the value <Mutually Defined "ZZ"> (where "ZZ" is the code which goes to the 837 file). But for the BCBS FL (Blue Cross Blue Shield) this value is <Duns (Dun & Bradstreet) "01">. See all available codes and values in the registry.
2. Carrier Type. This data element doesn’t go into 837 file directly but it determines the type of the payer which is very important for the 837 file logic (structure). For example there is a group of data which is required only when the destination payer is Medicare.
3. Doctor (business) EDI Mailbox. This data element usually is the same as your Mailbox number if you use, for example modem-to–modem connection to send 837 Professional Claim file. This number is business specific for the carrier. Some or all businesses may use the same EDI Mailbox.
4. Carrier EDI Mailbox. This data element usually is the same as the Carrier Mailbox number if you use, for example modem-to–modem connection to send 837 Professional Claim file, e.g. for Medicare FL it is equal to "911421656"
5. Doctor (business) EDI ID. This data element is a business specific for the carrier. Some or all businesses can use the same EDI ID.
6. Carrier EDI ID. This data element is a unique Carrier EDI ID number, e.g. for Medicare FL it is equal to "MEDBCLM00590"
7. Doctor (business) Submitter ID. This data element is usually the same as Doctor (business) EDI ID #5.
8. Carrier Submitter ID. This data element is usually the same as Carrier EDI ID #6.
9. Carrier EB Payer ID. This data element is unique EB Payer ID, e.g. for Medicare FL it is equal to "1000000M"
10. Doctor # Type. You can set this value by yourself. If the Carrier is Medicare, use <Medicare Provider Number "1C">. If BCBS, use 1B Blue Shield Provider Number "1B". If you are not sure, ask the Payer (Carrier). Note: the advantage of ANSI X12 EDI file is that we use code lists like Doctor # Type and don’t send whole name, only code, e.g. if you choose "Medicare Provider Number" you will see the code "1C" in the 837 file instead of whole name. To see all codes and names go to Registry information.
11. Doctor # or Group#. In most cases you have already these numbers. Please be cautious. If you enter a Group# which is actually the Provider # then TPS2000 generates 837 file containing only Group# and no matter what you have in Doctor# column. If the Group # is empty then the Doctor # goes into the 837 file.

Note:
* - Means that you may have this data already
** - This data is not determined in  ASC X12N 837 (004010X098A1) Implementation Guide but used in TPS 2000 for HIPAA to determine the Payer (Carrier) type.