EDI and HIPAA: Frequently Asked Questions

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General Questions
ANSI 837 Health Care Claims
ANSI 835 Remittance Advice
ANSI 270/271 Eligibility and Benefits Inquiry and Response
ANSI 276/277 Claims Status Inquiry and Response
ANSI 278 Referral Certification, Authorization Request and Response

If you have questions that are not addressed here, contact the Provider Assistance Unit (PAU). You may also e-mail EDI Services at ghc.edi@ghc.org. If your question is of general interest, we will add it to this list.

General Questions

Q. Where can I find the HIPAA implementation guides?

A. The ANSI HIPAA implementation guides are hosted by the Washington Publishing Company.

Group Health participated in the Washington Healthcare Forum (the Forum) workgroups that developed the HIPAA Transactions companion documents and best practices. Please refer to these documents to ensure that your transactions include the required data.

Q. Does this information apply to all Group Health plans?

A. Yes. It covers Group Health, Options, and Alliant Plans.

Q. How can providers exchange information with Group Health?

A. With Internet access, you can exchange information via MyGroupHealth for Providers (except for claims), batch exchange via secure FTP (including electronic claims), and clearinghouse data interchange. We do not offer automated telephone inquiry.

Q. If providers choose to exchange ANSI files directly with Group Health, is a third-party test required beforehand?

A. Yes. Early testing is best with a service that specializes in ANSI transaction testing. Examples of companies that provide such services include Edifecs and Claredi. Provider testing may be free from some of the testing companies. The advantage to providers is that feedback on test submissions is immediate. If providers are in production with another known organization, Group Health may waive certification requirements.

Q. How do Group Health and providers exchange HIPAA-compliant data?

A. For electronic claims, Group Health accepts claims from clearinghouses or from providers who opt to exchange information directly with Group Health.

Online transactions are available through MyGroupHealth for Providers website. The online transactions are content-compliant to HIPAA rules, a variation permitted by HIPAA and the nature of programming used for Web-based transactions.

Q. Is Group Health providing billing software?

A. No. Typically, submitters use the electronic billing capabilities of a medical office management system.

Q. Does Group Health have a dual-support strategy?

A. Yes. Group Health subscribes to the Forum dual-support approach.

Q. Must I sign a trading partner agreement with Group Health for EDI transactions?

A. It depends on how EDI transactions are submitted and by whom.

If you submit via a clearinghouse, providers will not have to sign a special trading partner agreement with Group Health. Your agreement will be directly with the clearinghouse.

If you are a Group Health contracted provider who exchanges transactions directly with Group Health, a special trading partner agreement is not needed.

However, other entities (like non-contracted providers, vendors, and so on) must sign the appropriate business associate and security agreements.

Q. Are all of Group Health's medical code sets HIPAA compliant, as defined in the ANSI implementation guides?

A. Yes.

Q. Is there a contact at Group Health for all HIPAA transaction questions and to support providers during the transition from proprietary (legacy) transactions to HIPAA compliance transactions and code sets?

A. Most questions should be directed to your clearinghouse, as your office will be testing with it and meeting requirements that it establishes. If your office decides to exchange files directly with Group Health, call the PAU or e-mail EDI Services.

Q. How will providers learn about changes?

A. Changes and updates for electronic claims will come from your clearinghouse, unless your office opts for submitting claims directly to Group Health. For direct exchange transactions, updates will be available in the companion documents on the Forum website.

Q. What is the turnaround time to respond to a batched transaction that has a paired reply (such as the 270/271 eligibility and benefits inquiry/reply)?

A. Usually within 24 hours. Depending on submission time relative to Group Health's after-hours batch processing, it could be more or less. For online submissions, results are immediate.

Q. How will the provider know that responses are completed and ready to be pulled in?

A. Responses to Web inquiries are immediate, so notification is not an issue.

The Group Health secure file transfer server can issue email notices of file availability. However, for convenience, you may opt to schedule downloads on a daily basis, with the expectation that responses to today's requests will be in tomorrow's download. Most users will likely have multiple file types and files for upload each day.

Q. Is there a maximum file size for batch files? How many claims can I make in one batch?

A. The maximum file size for batch files is 2,000 transactions.

Q. Is there a time-out standard for Web transactions when a no answer possible response will result?

A. Yes. The time-out is 60 seconds.

Q. How often is the information returned in my inquiry updated or maintained?

A. Transaction related data is updated nightly.

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ANSI 837 Health Care Claims

Q. What is the Group Health payor number that providers and office management vendors need to identify Group Health for electronic claims purposes?

A.The payor number is 91051; this may vary by clearinghouse.

If you are currently using code WA15, you may continue to do so.

Q. Will an Error and Acceptance Report be produced that reflects adjudication rejections?

A. Two types of error reporting will be available. Adjudication errors and rejections, as in the past, will be disclosed on your remittance advice, either on paper or in an ANSI 835 electronic remit.

Group Health is developing Error and Acceptance Reports that will run prior to acceptance of the claim that will not only reflect rejected claims and errors that may cause adjudication problems, but will also specify HIPAA compliance errors and omissions.

Q. Will Group Health continue to accept paper claims?

A. Yes. However, if you serve Medicare patients, HIPAA-compliant electronic claims are required except under very limited circumstances. If you are submitting claims electronically to Medicare, it may be a minor software update (or a simple payor table entry) for you to bill Group Health electronically. Check with your office management system vendor.

Medicare rule 42 CFR Part 424 details the requirements.

Q. How will requests for claims attachments be handled? Will an ANSI 277 Claims Status Response be used? Or will claims be rejected at the point of initial submission? What are typical claims attachments?

A. An ANSI 277 will not be used for this purpose. Claims will not be rejected at initial submission for lack of an attachment. If attachments, such as clinical reports, are required, Group Health will contact providers with a request after the claim is accepted.

Q. If one of the claims errors out of a batch, will the entire batch be rejected? How will rejected claims be processed?

A. If each claim is submitted between an SE and an ST segment, rejections will occur at a claim level. For more information, see the HIPAA Transactions companion documents.

Rejected claims will be reported on the Error and Acceptance reports and must be resubmitted after correction.

Q. Secondary claims can be submitted electronically (without the explanation of benefits or EOB) to all electronic payers, including Medicare Supplemental. (See WorkSmart Institute's Best Practice Recommendations for Exchanging Explanation of Payment Information between Providers and Health Plans, Using 5010v (PDF). Will Group Health accept secondary claims if all the required fields are completed according to the Implementation Guide for the 837 Health Care Claim form?

A. Secondary claims can be submitted without the EOB per Forum HIPAA Transactions Best Practices and companion documents. Medicare claims should be billed through the crossover process (preferred) or submitted on paper.

Q. Has anything changed concerning Health Care Common Procedure Coding System (HCPCS) on outpatient claims?

A. Yes. HCPCS are now required on all outpatient claims. Claim requirements (including HCPCS) are documented in the HIPAA Implementation Guides. Recommended conventions for our region can be found HIPAA Transactions companion documents.

Q. What is the time line for updating ICD-9 and CPT-4 codes?

A. Updates generally come out every quarter, with a comprehensive update at the first of the year.

Q. Are there any concerns or unique processing for late charges on bill types 135 or 115?

A. TOB 135 and 115 are no longer valid TOB codes since frequency code 5 is no longer valid. You must submit a replacement claim, frequency code 7. See the 837 Implementation Guide for the full set of valid variables.

Q. Does Group Health require the provider taxonomy code for claims adjudication?

A. Yes. Group Health does require the taxonomy code for adjudication and to identify the provider type. The ANSI 837 Claim Implementation Guide indicates this is a required field, thus it needs to be populated. Check the guide for more detail.

Q. Is Group Health in production with the 837 Health Care Claim form? Is Group Health currently accepting the ANSI 837 Health Claim transaction?

A. Yes. Group Health receives electronic claims through electronic claims clearinghouses. You may submit compliant transactions to the clearinghouse of your choice and they will be routed to us. Group Health is also testing the capability to receive 837 claims directly from submitters via secure FTP.

Q. Is Group Health currently using any codes other than the standard HCPCS, CPT, or ICD-9 codes to process/adjudicate claims?

A. No. Group Health will be moving to ICD-10 on Oct. 1, 2014. Claims submitted for dates of service after Oct. 1, 2014, should use the ICD-10 code set rather than ICD-9.

Q. How do you identify a provider organization as a submitter in the ANSI 837 format?

A. Identify a provider as submitter as follows:

  • ISA06: Interchange Sender ID (Tax ID)
  • GS02: Application Sender's Code (Tax ID); or
  • NM109, Loop 1000A: Submitter Primary ID (Tax ID)

Q. Which of the Patient Relationship to Subscriber codes will Group Health be using?

A. Claims should be submitted with each patient as the subscriber. The Individual Relationship Code value is 18 (self).

Q. Are there any concerns or unique processing issues for late charges? For adjusted billings?

A. For late charges, frequency code 5 is no longer valid. Providers must submit a corrected claim (adjusted billing) using frequency code 7.

Q. According to HIPAA documentation, patient weight is required only for erythropoietin (EPO) or Durable Medical Equipment (DME) patients. However, some companion documents still mention newborn weight. Will newborn weight be a requirement for your health plan?

A. Yes, for Institutional Claims with Revenue Code 170 or Admit Source 4, you must submit Value Code 54 with birth weight.

Q. Does Group Health want anesthesia charges billed with minutes or units?

A. Minutes.

Q. Will Group Health require DME Service (Loop 2400, SV5)? If so, for which DME item is it required?

A. Yes, it is required for all DME items.

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ANSI 835 Remittance Advice

Q. Will paper remittance advice (RA) forms be sent along with the electronic version? If so, for how long?

A. A paper RA form will be sent only upon request. InstaMed acts as our clearinghouse to distribute our electronic remit advice (ERA), our electronic funds transfer (EFT), and when necessary a paper check and/or paper advice.

Q. During testing with provider groups, can providers receive an 835 RA for 837 Professional and 837 Institutional Health Care Test Claims?

A. Yes, but only if the provider has submitted test claims using Group Health's test members.

Q. Will electronic funds transfer be offered? If not, will there be a lag between the ERA and receipt of payment?

A. Yes, working with our partner InstaMed EFT is available.

Q. If providers send claims in a hardcopy format, will an ANSI 835 Remittance Advice be available?

A. Yes.

Q. Will coordination of benefits (COB) be done automatically through the ANSI 835 Remittances? All payors? What about Medicare crossovers?

A. If Group Health is the secondary payor; we will process COB claims as long as the claim is submitted in accordance with the Forum Administration Simplification Policies and Guidelines. If Group Health is the primary payor, you will need to submit the secondary claim in accordance with the guidelines of the secondary payor.

Q. Will a crosswalk (translation table between old and new) be created to tie existing payment and adjustment codes to the new standardized 835 Remittance Advice remark codes?

A. You may request a crosswalk, but it will be of limited value because there is a many-to-one relationship between the prior Group Health action codes and the 835 Adjustment Reason codes.

Q. If claims are sent via hardcopy, how will payments be made?

A. You may request an electronic or paper remittance advice, or for the time being, both. Payments will be electronic or paper depending on your prior arrangements with our EFT partner, InstaMed.

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ANSI 270/271 Eligibility and Benefits Inquiry
and Response

Q. What standard data elements are required for submitting an ANSI 270 Eligibility and Benefits Request?

A. Three out of the four data elements listed below are required to search eligibility on the Contracted Providers website:

  • Member ID
  • First name
  • Last name
  • Date of birth

To determine past eligibility for all inquiries, change the date of service (the default is today) to the date in question. Batch inquiries will use the 270 transaction as defined in the Implementation Guide and Companion Document.

Q. What information will be provided in the 271 Eligibility and Benefits Response?

A. The 271 response will include:

  • Member Demographic Information: Includes address, phone number, DOB, member ID, gender, Medicare #, Medicare ID.
  • Primary Group Health Coverage: For members with primary coverage through Group Health. Includes group number, group name, health plan, effective and term dates, copay amounts, deductible amount.
  • Secondary Group Health Coverage: For members with secondary coverage through Group Health: group number, group name, health plan, effective and term dates, copay amounts, deductible amount.
  • PCP Information: Name, location, effective date (with member), and office # of member's primary care provider.

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ANSI 276/277 Claims Status Inquiry and Response

Q. What standard data elements are required to submit a MyGroupHealth for Providers claims status inquiry?

A. For a quick search, use either the patient account number or the claim number. Or search using any combination of the following:

  • Patient account number
  • Member ID
  • Member name
  • Member date of birth
  • Claim status type
  • Date of service range
  • Provider name
  • Provider number

Q. What information will be provided in the claims status response?

A. The response will include:

  • Patient account #: A tracking number assigned by the provider.
  • Last name: The member's last name.
  • Claim number: The Group Health claim number.
  • DOS: The first date of service on the claim.
  • Bill amt: Total for all the services that Group Health processed on the claim.
  • Paid amt: The completed claim paid dollar amount. Includes amount paid all or part from offset.
  • Group Health status: The status of the claim in the Group Health system.
  • Patient name: Patient's last name then first name.
  • Member ID: Patient's Group Health member identification number.
  • DOB: Patient's date of birth.
  • Claim #: Group Health claim number.
  • Provider name: Name of provider or facility submitting claim.
  • Check #: Number of the check Group Health sent to the provider.
  • Check/completion date: Date Group Health cut check to the provider. If Group Health has not finished processing the claim, this field will show, "In Process".
  • Paid amt: Paid dollar amount of the completed claim. Includes any payment rendered in total or part from offset.
  • HIPAA status: HIPAA-designated claim status code for the claim.
  • HIPAA description: Description of the HIPAA category/status code designating the status of the claim in the Group Health payment system.
  • Status: Code designating the status of the claim in the Group Health payment system.
  • Status description: Description of the status of the claim in the Group Health payment system.
  • Patient responsibility: Amount the Group Health member is responsible for paying. The same information will be contained in a MyGroupHealth for Contracted Providers Web response as in a batch ANSI 277 Claims Status response.

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ANSI 278 Referral Certification, Authorization Request, and Response

Q. Will the need for provider-initiated follow-up calls to Group Health be clearly indicated in the ANSI 278 Referral Response?

A. Referral status inquiry is available on MyGroupHealth for Contracted Providers. Batch referral requests will generate batch responses and Group Health will contact you if additional information or action is required, so follow-up calls initiated by the provider should not be necessary.

Q. How will supporting documentation for electronic referrals be sent? Is there a time line for submission?

A. The Forum clearly defines the requirements for referral, pre-authorizations, and related topics for member health plans. See the ANSI 278 Companion Document for complete instructions for submission of these requests to Group Health.

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Revised 11/1/2013