Helpful Hints to Successfully Submit ANSI 837 Claims through Availity The Health Care Industry is in the process of implementing significant changes for electronic submissions. The purpose of this document is to help EDI claims senders and vendors avoid potential problems when migrating to the new ANSI 837 HIPAA format through Availity . Below you will find critical information to assist the migration of your electronic commercial (non-Medicare) health care claims to Availity. If you are a vendor or a clearinghouse, please share this document with your senders and/or providers.
Helpful Hints
Edit Type
1.
BCBSF
Sender Code – The 5 digit Blue Cross and Blue Shield of Florida (BCBSF) sender code must be submitted on all claims routed through Availity. Currently, all BCBSF sender codes for Availity users begin with a G or H prefix. Failure to submit your BCBSF Availityuser sender code will result in the claim not being forwarded for processing. You would then need to electronically resubmit the claim using the BCBSF Availity-user sender code. a. ANSI 837 - Loop 1000A, NM109 BCBSF Provider ID – This identifier is required for BCBSF, even though it is listed as optional in the HIPAA Implementation Guide. Claims will fail at Availity as a payer specific edit if the provider ID for billing and/or rendering physician/facility is missing or at BCBSF if it is invalid. These claims must be resubmitted electronically with the appropriate BCBSF provider ID. The following BCBSF provider IDs are required: a. Billing Provider or Payee – always required ANSI 837 Professional: 2010AA or 2010AB, Institutional: Same as professional NSF Professional: Rec BA0 02, Institutional: Rec 10 - 12 CMS-1500, block 33 UB-92, block 1
Availity
b. Claim or line level rendering physician for professional claims – Required when the Physician is different from the billing provider or payee (PA groups must provide the BCBSF provider ID for the physician who rendered the services unless previous arrangements have been made with BCBSF). ANSI 837 - Loop 2310B or 2420A NSF: FA0 23 CMS-1500 block 24K
BCBSF Processing
Note: Claim and/or line level rendering physician information is not required if it is the same as the billing provider or payee (i.e., labs or hospitals). 3.
a.
Inpatient services for professional claims - For place of service 21, 51, or 61, claims must include the facility name and complete address. a.
Facility name and address:
BCBSF Rev. 10.21.03
ANSI 837 - Loop 2310D, NM1 03; N3; N4 NSF – EA0-37; EA1-6 through 10 CMS-1500, block 32 b.
4.
Place of Service Information ANSI 837 - Loop 2300, CLM05-1 = ‘21’, ‘51’, ‘61’ NSF – FA0-7 CMS–1500, block 24B
Quantity segment (QTY) - Required for all institutional inpatient services. Number of covered days as indicated by the “CA” qualifier.
BCBSF
Availity (Payer edit)
This information is always required, even if the number of covered days is zero. Other days are optional such as non-covered, etc. ANSI 837 – Loop 2300, QTY01= ‘CA’, QTY02= # of days NSF 1450 - 30, Field 20 UB-92, block 7 5.
Only original claims can be accepted electronically at this time for professional claims. a.
Availity (Payer edit)
Corrected, adjusted or voided claims will be rejected. ANSI 837 - Loop 2300, Segment/Element CLM05-3 must =1
6.
Currently, interim bills for institutional claims cannot be accepted electronically. ANSI 837 - Loop 2300, Segment/Element CLM05-3 must equal NSF – Record 10-2, position 3; 40-4, position 3; 95-5, position 3 UB-92 block 4, position 3
Availity (Payer edit)
7.
Availity will not accept claims containing dates of service for 2001 or earlier.
Availity
The error message will be “the HCPCS code is invalid”. The date of service field location is: ANSI 837 – Loop 2400, Segment/Element DTP01 = ‘472’, DTP03 = Date of Service NSF 1500 – Record FA0-05 and FA0-06 NSF 1450 – Record 60, Field 12 though 14 or Record 61, Field 9, 14 & 15 CMS–1500, block 24A UB-92, Block 6 or 45 8.
Professional Ambulance claims – Ambulance services must include CR1 and CRC segments according to the HIPAA Implementation Guide.
HIPPA / BCBSF
a. BCBSF identifies ambulance services by place of service 41 or 42. Although required by HIPAA, BCBSF currently may not use the information submitted on these segments. ANSI 837 - Loop 2300, Segments CR1 and CRC NSF – Record GA0 9.
Gender Codes - BCBSF currently only accepts gender codes M and F. The submission of a “U” will result in a claim rejection at Availity and will not be forwarded to the payer. a.
Page 2
Availity (Payer edit)
Subscriber Information ANSI 837 – Loop 2010BA (Subscriber), Segment/Element DMG03 NSF 1500 – DA0-23 ; 1450 – 30-15 CMS-1500, block 11A;, UB-92, block N/A
Rev. 10.21.03
b.
Patient Information ANSI 837 – Loop 2010CA, Segment/Element DMG03 NSF 1500 – CA0-09; 1450 – 20-07 CMS-1500, block 3; UB-92, block 15
10.
Coordination of Benefits (COB) - BCBSF will accept electronic COB claim data as of October 16, 2003. Until then, BCBSF will only accept electronically submitted claims if BCBSF is the primary payer.
11.
Member Identification Number - BCBSF requires the member ID on every claim. This number is identified by the MI qualifier on the ANSI 837 format. ANSI 837 - Loop 2010BA, NM108 must be MI NSF 1500 – DA0-18; 1450 - Record 30, field 7 CMS-1500, block 1A UB-92. block 60 A-C
Availity (Payer edit)
Important New HIPAA Requirements (not BCBSF specific): •
Subscriber’s Date of Birth - required on all claims when the subscriber is the patient or when other insurance is reported on both professional and institutional claims.
•
Line Level Date of Service – is now required on all outpatient service lines containing a revenue code or HCPCS code.
•
Anesthesia claims - must indicate minutes, not units (MJ qualifier, not UN qualifier – CMS-1500, block 24G).
Page 3
Rev. 10.21.03
Frequent Claim Submission Errors/Issues
1.
Errors Invalid/discontinued HCPCS procedure and/or modifier codes
2.
Service dates earlier than 2002
Type of Edit Availity HIPAA Availity
3.
Invalid headers or trailers
Availity
4.
Invalid/missing subscriber date of birth
5.
Invalid/missing service line date for institutional outpatient claims
6.
Invalid payee qualifier for BCBSF ID (i.e., 1B when it should be 1A)
7.
Duplicate submissions (duplicate files and duplicate claims)
8..
Invalid bill type
Availity HIPAA Availity HIPAA Availity (Payer edit) Availity BCBSF BCBSF
9..
Invalid sender code
BCBSF
10.
Missing or invalid BCBSF provider ID
11.
Invalid attending physician for institutional inpatient services
Availity BCBSF BCBSF
12.
Invalid facility name and address for professional inpatient services
BCBSF
13.
Test claims submitted to the Availity production system
14.
Future or ‘unreasonable’ dates (i.e., patient’s birth date submitted as 01/01/1476. date and format are technically valid, te and the format is appropriate but it is an ‘unreasonable’ birth date for a person receiving medical services)
Availity BCBSF BCBSF Processing Systems
The
Should you have additional questions concerning this document, please contact the Availity Customer Service Center at 1-800-AVAILITY (1-800-282-4548).
Page 4
Rev. 10.21.03
