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HIPAA FAQs

HIPAA Transactions and Code Sets

Note: The following responses indicates the process that BCBSRI has implemented based on our interpretation of the HIPAA regulations.

Are small provider practices exempt from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Transactions and Code Sets regulations?

No. Regardless of practice size, all providers transmitting designated transactions electronically are subject to the HIPAA Administrative Simplification requirements. Effective October 16, 2003, small practices are exempt from the Administrative Simplification Certificate Act (ASCA) provision that excludes paper claims from Medicare coverage. Small practices will be able to continue to submit paper claims. ASCA defines a small practice or supplier as:

  1. A provider of services with fewer than 25 full-time equivalent employees or
  2. A physician, practitioner, facility or supplier (other than provider of services) with fewer than 10 full-time equivalent employees.

Where can I find HIPAA-related information on the BCBSRI Web site?

You can access HIPAA-related information from either the Employer tab or Provider tab at www.BCBSRI.com. While most of the information that addresses Trading Partner specifics is the same, there are documents particular to our physicians and institutions (Provider tab) and to our groups and accounts (Employer tab).

What is the process for obtaining the "production green light" for submitting ANSI X-12 transactions?

BCBSRI has developed a Partner Testing approach to ensure Trading Partner transactions are HIPAA compliant and meet BCBSRI's business rules. The extensive testing required during the Partner Testing phase should result in a smooth transition to production. In general, the major components are:

For additional information on HIPAA Partner Testing and qualifying for production, contact BCBSRI's Information Assurance Department. Contact information is also available on www.BCBSRI.com. Our knowledgeable staff will work with you during each step of Partner Testing in preparation for production submission/receipt of ANSI X12 transactions.

Where can I get a copy of BCBSRI's Companion Guide for submitting/receiving Corporate ANSI X12 transactions?

You can obtain copies of all BCBSRI's Companion Guides here. There, you can find current versions of the guides. This is the best place to obtain this information.

The Institutional and Professional Implementation Guides do not specifically address what format to use when submitting home infusion claims. How will BCBSRI process a home infusion claim submitted as an 837 Institutional claim? How will BCBSRI process a home infusion claim submitted as an 837 Professional claim?

BCBSRI's EDI Gateway must accept any ANSI-compliant home infusion claim submitted on either X837I or X837P. However, we are free to reject - and will reject - any X837P home infusion claim during the internal business editing process as "not a contracted service for this form type". A home infusion provider would have to use the X837I format in order to receive payment under the terms of their contract.

I'm a provider who is using a valid CPT code for something other than for what it is defined. There is no available code that accurately identifies the program and reimbursement arrangement BCBSRI has with the provider. If the provider continues to use this code in that way, would this be in violation of HIPAA compliance?

BCBSRI can not process local codes after October 16, 2003 . During the last few years, we examined all of our existing local codes. We found that many of the codes had not been used for several years, so they were "end-dated" and made unavailable in our system. Other local codes were found to have exact matches with newer national standard codes, so those local codes could be likewise discarded and replaced by the appropriate standard code. Other local codes, however, had no clear national code equivalent. In those cases, we attempted to match the existing local code to the closest valid national code and eliminate the local code.

In the situation described above where there is no clear national code set equivalent, the closest valid national code set was selected and will be used to process those claims. In that case, we made a good faith effort to map the service to the appropriate national code, and we should be allowed to continue that practice.

How are workers' compensation claims handled?

Workers' compensation programs are not considered a "covered entity" under the federal HIPAA statute. From the Federal Register:

"We recognize that non-HIPAA entities such as workers' compensation programs and property casualty insurance accept electronic transactions from health care providers, however, the Congress did not include these programs in the definition of a health plan under section 1171 of the Act.

The statutory definition of a health plan does not specifically include workers' compensation programs, property and casualty programs, or disability insurance programs, and, consequently, we are not requiring them to comply with the standards. However, to the extent that these programs perform health care claims processing activities using an electronic standard, it would benefit these programs and their health care providers to use the standard we adopt."

This means that workers' compensation programs are not covered by any of the various components of the HIPAA legislation. Since workers' compensation is outside the scope of HIPAA regulations, BCBSRI decided to allow submission of the X837 with non-standard codes for workers' compensation. If non-standard health service codes are used, the ZZ qualifier must be used with the local code and the claim must be marked as work-related(CLM-11= EM) to avoid edit rejects. BCBSRI is free to accept any of the HIPAA transactions with non-covered entities. In those cases, non-standard code sets are allowable as long as both sides of the relationship are in agreement.

All of my Beacon claims are being rejected because of the local common procedure codes and revenue code 0930. I am following the companion guide by using qualifier ZZ in the SV2 segment. Why are these claims being rejected?

There is a list of local codes that would be used in conjunction with the ZZ qualifier. They begin with X7001 and go to Y3160 (approximately 20 codes).

Attending Physician (SLF000) is being rejected. When applicable, we currently use this code in our UB electronic billing. Can we still use it?

SLF000 is allowed for Attending Physician on a Professional ANSI claim format. As of October 16, 2003 , SLF000 is also allowed for Attending Physician on an Institutional ANSI claim format. As of 5/23/2007 , SLF000 will no longer be accepted with the proposed implementation of the National Provider Identification(NPI) number.

In the ANSI file, the Carrier Reference (Payer ID) for BCBSRI must be 00870 for Blue Shield/ Blue Chip and 00370 for Blue Cross/Blue Chip.

Any other Payer id will not be recognized by our system.

How is an 837 claim that has more than 28 lines handled within BCBSRI?

We accept the HIPAA limits - 50 lines for Professional claims and 999 lines for Institutional claims. If a claim greater than 28 lines is encountered, we route it to the Claims Department via paper, where it is manually split into separate claims, then entered into our system. The claim is entered into multiple claims with the Repository, Split Claim Indicator, Patient Control Number, and Line Indicator being entered on the claims. The Line Indicator will show the original number of the line it had (e.g., If line 30 on the original claim dropped to paper, 30 will be entered on the line level Line Control Number field). From that point, the pieces are independent claims in our system. Parts of the original claim could be paid in different settlements. However, the provider's original control information - including the provider-submitted original line number - will be returned in the 835s.

Should there always be a 997 Acknowledgement for each 837 file submitted?

You should always expect a 997 Acknowledgement and Plain Language 997 for each 837 file you submit. If a reasonable time has elapsed since file submission and you have yet to receive the appropriate 997 during Partner Testing with BCBSRI, please e-mail BCBSRI's Information Assurance Department at hipaa.edi.support@bcbsri.org or call (401) 459-1970. If this is a production file, please contact our IT Help Desk at (401) 751- 1673 for assistance.

It appears that the translator/editor is rejecting a batch as soon as it encounters an error. Is this true? How do I know what kind of data errors trigger a failed 997?

Our translator/editor will attempt to edit as much as possible. However, our system will reject the entire batch at the first occurrence of an error within an ST-SE grouping. Using multiple ST-SE allows our system to edit on each individual instance of this grouping. The 997 will report the edit based on the ST-SE, whether it is one or multiple. The AK5 segment indicates if the batch was accepted or rejected. Rejections will include the appropriate error code, which can be found and defined within the IG. The AK3 segment points to the segment and position within the segment that is in error and it may be repeated if multiple ST-SEs are reported on the 837.

The 997 Acknowledgement transaction does not provide enough information to analyze and correct data. It does identify the erroneous segment, but it does not tell you where it is located in the file. For example, I recently sent a file of approximately 1,000 BCBSRI claims. The 997 told me that a SV2 segment was rejected, but it did not give me any additional information so I could find it in the transaction set. In this particular file, there were thousands of SV2 segments. How am I to determine which SV2 rejected?

At this time, limited information is returned on a 997 Acknowledgement transaction. You may use your login for the Foresight Online Validator tool to determine the error with your production files, as well as files you may be testing.

Is BCBSRI still offering the contingency plan for the electronic settlements

Yes. BCBSRI will continue to offer the current electronic settlements to providers during the contingency plan period.

If I submit electronic claims using the ANSI X-12 837 format, will I still be able to receive settlements in the old format during the contingency plan period?

Yes. The source of the claim input is not considered when producing a settlement. A provider can submit either an X837 or proprietary format claim and receive either an X835 Electronic Remittance Advice transaction or the current electronic proprietary format settlement. The provider is free to make this choice as long as the contingency plan is in effect.

Will providers continue to receive the current paper settlement summary?

Yes. The current paper summary will be produced as a "business report" and made available to the submitter. The format of the report has changed slightly to accommodate new fields such as National Drug Code (NDC). There will also be modifications of the paper settlement to accommodate the NPI id.

Will BCBSRI offer "turnkey" conversion to the X835 ERA Settlement? In other words, will all settlements be in X835 format as of a predetermined date?

Yes. BCBSRI will provide conversion to X835 settlements in "turnkey" fashion. Once a provider is ready to accept the ANSI X12 X835 transaction and has passed all Partner Testing criteria, the provider should notify BCBSRI's Information Assurance Department of their readiness for production conversion. They will then update their databases to indicate that the provider is ready to accept X835 transactions in production. Once the database is updated, all future settlements will be presented to the provider in ANSI X12 X835 format, regardless of the date of service for the claims on that settlement.

Will I be able to receive BOTH the current proprietary claim settlement transaction and the new ANSI X12 X835 transaction during the contingency plan period?

Yes. BCBSRI recognizes that financial settlement is a key business function for our trading partners. Therefore, we will make both the current proprietary settlement and the corresponding ANSI X12 X835 available to submitters during the contingency plan period. In this way, providers will be able to view the results of their claim submissions using a familiar format and then view how the same claims are reported using the X835 transaction.

After getting the "go ahead" for submitting ANSI X12 claims in production, will there be changes I need to make? If so, what are those changes?

Yes. There are three changes you will need to make. The first change is in the first position of the Submitter ID, which will change from a "T" (Test) to a "P" (Production). The second change is a new password that will be randomly generated to provide a secured environment. Information Assurance staff will provide you with your new password and the process for moving into a production environment.

I am in end-to-end partner testing, and I did not receive a 997 Acknowledgement within a short time after submission. Why?

If a reasonable time has elapsed since file submission and you have yet to receive the appropriate 997 during Partner Testing with BCBSRI, please e-mail BCBSRI's Information Assurance Department at hipaa.edi.support@bcbsri.org or call (401) 459-1970. It is possible that there is incorrect data on the transmitted file. This incorrect data would prohibit our software from determining which mailbox should receive the 997 Acknowledgement information. A few examples of this would be an incorrect Submitter ID Number, an invalid trade-link, and invalid qualifiers.

I have "Provider Control Reports" in my mailbox directory. What is the purpose of these reports?

The Provider Control Reports identify claims that were not accepted for claims adjudication. This reject report will list any claim that is rejected from our front-end edit process and the reason the claim rejected. These claims must be corrected by you and resubmitted for processing.

What are BCBSRI’s plans for the NPI (National Provider Identification) number?

BCBSRI will be required to handle and accept NPI on all standard HIPAA transactions effective 5/23/2007 , and any standard transaction being sent to a covered entity must use NPI. In addition, any direct data entry into a BCBSRI system, such as our BCBSRI website, is considered an electronic transaction and must be HIPAA compliant.

Any electronic claim coming in, regardless of the date of service on 5/23/07 or after must be filed with the Billing Provider NPI and Rendering Provider NPI, if different than the billing NPI. We are making changes to our internal systems, reports and processes for this mandatory change. We are also requiring the NPI on all paper forms such as the UB04 and CMS1500 forms.

What will happen if a provider submits claims with NPI prior to the implementation date?

If a provider decides to use the NPI prior to the implementation date, the NPI will be ignored and not used for processing. Therefore, providers will need to continue to use the BCBSRI-supplied Provider ID to transact business/file claims until May 23, 2007.

What is the difference between a Type 1 and Type 2 NPI?

Type 1 NPI’s are health care providers who are individual human beings. Type 2 NPI’s are organizations, facilities, hospitals, home health agencies, labs, dme suppliers, etc.

How do I get an NPI?

The Centers for Medicare and Medicaid Services has contracted with Fox Systems to serve as the National Plan and Provider Enumerator. You may request your NPI via the following methods:

By Phone: 1-800-465-3203 (NPI Toll Free) or 1-800-692-2326 (NPI TTY)
By E-mail: customerservice@npienumerator.com
On the web: nppes.cms.hhs.gov
By mail: NPI Enumerator, PO Box 6059 , Fargo , ND 58108 -659