4010A1 Inbound Professional Claim Companion Document

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicare, and all other health insurance payers in the United States, comply with the EDI standards for health care as established by the Secretary of Health and Human Services. The X12N 837 implementation guides have been established as the standards of compliance for submission of claims for all services, supplies, equipment, and health care other than retail pharmacy prescription drug claims. The implementation guides for each X12 transaction adopted as a HIPAA standard are available electronically at http://www.wpc-edi.com.

The following information is intended to serve only as a companion document to the HIPAA X12N 837 professional claim implementation guide. The use of this document is solely for the purpose of clarification. The information describes specific requirements to be used for processing data in the Triple-S Inc. / Medicare system of Triple-S Inc. Contractor number 00973. The information in this document is subject to change. Changes will be communicated in the standard Medicare Informa bulletin and on Triple-S Inc. / Medicare Web site: www.triples-med.org. This companion document supplements, but does not contradict any requirements in the X12N 837 Professional implementation guide.

General Statement

• The maximum number of characters to be submitted in the dollar amount field is seven characters. Claims in excess of 99,999.99 will be rejected.
• Claims that contain percentage amounts with values in excess of 99.99 may be rejected.
• Claims that contain percentage amounts cannot exceed two positions to the left or the right of the decimal. Percent amounts that exceed their defined size limit will be rejected.
• Triple-S Inc. / Medicare will convert all lower case characters submitted on an inbound 837 file to upper case when sending data to the Medicare processing system. Consequently, data later submitted for coordination of benefits will be submitted in upper case.
• Only loops, segments, and data elements valid for the HIPAA Professional Implementation Guides will be translated. Submitting data not valid based on the Implementation Guide will cause files to be rejected.
• The incoming 837 transactions utilize delimiters from the following list: >, *, ~, ^, |, and :. Submitting delimiters not supported within this list may cause an interchange (transmission) to be rejected.
• You must submit incoming 837 claim data using the basic character set as defined in Appendix A of the 837 Professional Implementation Guide. In addition to the basic character set, you may choose to submit lower case characters and the '@' symbol from the extended character set. Any other characters submitted from the extended character set may cause the interchange (transmission) to be rejected at the carrier translator.
• When applicable, the National Provider Identifier (NPI) must be submitted in the NM109 segment (NM108 = XX).
• Medicare does not require taxonomy codes be submitted in order to adjudicate claims, but will accept the taxonomy code, if submitted. However, taxonomy codes that are submitted must be valid against the taxonomy code set published at http://www.wpc-edi.com/codes/taxonomy. Claims submitted with invalid taxonomy codes will be rejected.
• All dates that are submitted on an incoming 837 claim transaction must be valid calendar dates in the appropriate format based on the respective qualifier. Failure to submit a valid calendar date will result in rejection of the claim or the applicable interchange (transmission).
• Triple-S Inc. / Medicare may reject an interchange (transmission) submitted with more than 9,999 loops.
• Triple-S Inc. / Medicare will reject an interchange (transmission) submitted with more than 9,999 segments per loop.
• Triple-S Inc. / Medicare may reject an interchange (transmission) with more than 999 CLM segments (claims) submitted per transaction.
• Compression of files is not supported for transmissions between the submitter and Triple-S Inc. / Medicare.
• Any qualifiers submitted for Medicare processing which are not defined for use in Medicare billing may cause the claim or the transaction to be rejected.
• You may send up to four modifiers; however, the last modifier may not be considered. The Triple-S Inc. / Medicare processing system may only use the first three modifiers for adjudication and payment determination of claims.
• Triple-S Inc. / Medicare will edit data submitted within the envelope segments (ISA, GS, ST, SE, GE, and IEA) beyond the requirements defined in the Professional Implementation Guides.

Interchange Control Header

Functional Group Header

Transaction Set

Claim Information

997 - Functional Acknowledgement

• We suggest retrieval of the ANSI 997 functional acknowledgment files on the first business day after the claim file is submitted, but no later than five days after the file submission.
• Triple-S Inc. / Medicare will return the version of the 837 inbound transaction in GS08 (Version/Release/Industry Identifier Code) of the 997.