Friday, August 12, 2016

General instruction on EDI 873 FORMAT

General Instructions

** All NPIs on claims submitted to Tufts Health Plan must be registered with the Provider Information Department prior to transmission. Please call (888) 880-8699 x3153 to verify or register the NPIs of your organization with Tufts Health Plan.

** Tufts Health Plan will require a valid NPI when NM109 is used in any provider loops and will not accept Provider Secondary Identification after the mandated NPI Implementation date.

** New submitters must go through the appropriate set-up/authorization process in order to transmit electronic claims with Tufts Health Plan.
Please refer to the Communications/Connectivity Component of this document for details.

** Tufts Health Plan will accept 837 Institutional and 837 Professional Claim Transactions for all business products, however the 837 Institutional and 837 Professional claim files must be sent separately. They cannot be sent on the same file.

** As stated in the technical reports, a maximum of 5000 CLM segments will be accepted by Tufts Health Plan.

** Tufts Health Plan is adhering to structural specifications for required and situational fields as stated in the technical reports. If the incoming 837I or 837P has a single ST/SE and the structure does not comply, the entire file will fail in the validation process. If the incoming 837I or 837P has multiple ST/SEs, only the failed ST/SEs in the file will fail in the validation process. The submitter receives a 999 acknowledgement for notification for the ST/SEs that failed.

** Tufts Health Plan will capture payee information from the Billing Provider Name loop (Loop 2010AA).

** The Pay-To Address Name loop (Loop 2010AB) in 5010 has been changed to enter a separate billing provider address where payments should be sent. Please note that Tufts Health Plan will continue making payments to the addresses in our backend system database instead of the addresses submitted in loop 2010AB.

** Tufts Health Plan cannot currently support billing for atypical provider type submissions.

** For Frequency Types 5, 7, and 8, (Element CLM05-3), Tufts Health Plan’s original claim number (Original Reference Number – Element REF02) must be submitted as stated in the technical report. We also strongly recommend sending the Original Reference Number with Frequency Types 2, 3, and 4.

** When contacting Tufts Health Plan with questions for claims with Frequency Types 2, 3, 4, 5, 7, and 8, (Element CLM05-3), please use the original claim number even though a new claim number for that submission will be assigned.

** The Tufts Health Plan implementation of Coordination of Benefits (COB) Information utilizes claim header information in the COB Header Other Subscriber Information (Loop 2320), Other Subscriber Name (Loop 2330A), and Other Payer Name (Loop 2330B) as well as line level information in the Line Adjudication Information Details (Loop 2430) within the 837 transactions. We strongly recommend closely reviewing these loops in the technical reports before submitting COB information. Many data segments have been changed or deleted.

** Although the HIPAA Transaction Set technical report allows the repeating of Billing Provider Name loop (2010AA Loop) for each claim, the size of transmission files can be reduced by up to 20% by using only one repeat of Billing Provider Name loop followed by all subscriber and claim information for that Provider. Transmission files can be further reduced by grouping the claims of each subscriber together.

** ICD-10 Codes will not be accepted until the regulatory compliance effective date of October 1, 2014.

** For compliance purposes, Tufts Health Plan will only accept qualifier MJ for minutes when billing anesthesia procedure codes. UN is a valid qualifier for procedures other than anesthesia.

** Tufts Health Plan is unable to accept claims submitted electronically with charges total one million dollars (or more) due to system limitations.

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