HIPAA EDI Companion Document
Introduction
At Deseret Mutual, we’re currently accepting HIPAA-compliant transactions through UHINet,
a product of the Utah Health Information Network (UHIN). For more information about UHIN
and its products, visit www.uhin.org.
We can receive and generate the following HIPAA-compliant transactions:
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837 004010X098A1 (professional claim)
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837 004010X096A1 (institutional claim)
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837 004010X097A1 (dental claim)
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270/271 004010X092A1 (eligibility — both batch and real time)
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276/277 004010X093A1 (claim status — both batch and real time)
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835 004010X091A1 (remittance)
If you want an 835, call our Provider Maintenance Team toll free at 1-800-777-3622
or 1-801-578-5600 in the Salt Lake City area. Press options 1, 3, and then 4 for
the Provider Maintenance department. Or e-mail us at edienrollment@dmba.com.
For all claims submitted through UHINet, we’re generating an unsolicited 277 claim
status transaction (referred to as the 277FE or 277 Front End acknowledgment).
This is not a HIPAA-related transaction and is in a 004020 format
(visit www.uhin.org for the implementation
guide; see How We Use the Unsolicited 277FE below for how we use this
transaction). The 277FE replaces and enhances the functionality of the 864 text message for
relaying information on submitted claims.
How to Enroll for EDI Transactions
To submit claims electronically (EDI claims submission), please complete the
Electronic Billing Enrollment Form
and return it to Deseret Mutual either by e-mail, fax, or mail.
Once we receive this form, we’ll contact you to begin the testing process.
For more information about our testing procedures, see the Testing Procedures section below.
If your practice is already set up for EDI claim submission and a new provider joins
the practice at a later date, please contact Deseret Mutual to enroll that provider for EDI claim submission.
An NPI is required for all EDI transactions. If you need more information about NPIs,
call UHIN at 1-801-466-7705, ext. 204, or visit the dedicated CMS Web page
(http://www.cms.hhs.gov/nationalprovidentstand).
Deseret Mutual doesn’t store payer ID numbers assigned by clearinghouses (typically 5 digits).
To obtain Deseret Mutual’s payer ID number, please contact your clearinghouse.
If you have additional questions about EDI submission, call a Provider Maintenance Representative toll free at 1-800-777-3622
or 1-801-578-5600 in the Salt Lake City area. Press options 1, 3, and then 4 for
the Provider Maintenance department. Or e-mail us at edienrollment@dmba.com.
Testing Procedures
When you contact Deseret Mutual to enroll for EDI claims submission, we’ll set
you up for testing. Please send all test claims through the production mirror
UHIN portal to our test trading partner number (listed below). Payments will
not be generated for these test claims. While in this testing phase, if any
claims are submitted through the production portal to our production or test
trading partner numbers, or if any claims are sent through the production mirror
portal to our production trading partner number, they will not be processed.
Testing Information
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Production Mirror
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Sundance
|
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Test Trading Partner Number
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HT000006-003
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We expect to receive test claims with actual (as opposed to made-up) data.
For example, we don't want to receive claims for Mickey Mouse with subscriber
ID 999999999. We will analyze the structure and content of the transactions
we receive and we’ll contact you. We’ll let you know if either a) we did not
encounter any problems and we’re ready to accept your claims in a production mode,
or b) we encountered problems that need to be addressed before we can switch to a production mode.
Note: If the claims you submit for testing are claims for which you expect payment,
these claims must be resubmitted once we have approved the switch to production.
We will NOT automatically migrate test claims to our production system.
Once you’ve completed testing and been cleared by the Provider Maintenance Team to
begin submitting claims for adjudication, submit all claims through the production portal
to our production trading partner number. After you’ve been moved out of the testing phase,
any claims submitted through the production mirror to our test trading partner number will
still be processed as test claims and not paid. Any claims sent through the production
mirror to our production trading partner number will not be processed at all.
Production Information
|
Production Portal
|
Butch
|
|
Production Trading Partner Number
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HT000006-001
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The examples below show the billing loops for NPI. The mock NPI is 1234567890.
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BILLING PROVIDER
Place the NPI in the NM1 segment of loop 2010AA (Billing Provider),
qualified by an XX. The REF segment will be included to report the Tax
Identification number (TIN) qualified by an EI. For example:
HL*1**20*1
NM1*85*2*BILLING*PROVIDER****XX*1234567890
N3*123 MAIN STREET
N4*SALT LAKE CITY*UT*84111
REF|EI|870000000
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PAY-TO PROVIDER
Place the NPI in the NM1 segment of loop 2010AB (Pay-To Provider), qualified by an XX.
The REF segment will be included to report the Tax Identification number (TIN)
qualified by an EI. For example:
HL*1**20*1
NM1*87*2*PAY-TO*PROVIDER****XX*1234567890
N3*123 MAIN STREET
N4*SALT LAKE CITY*UT*84111
REF|EI|870000000
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RENDERING PROVIDER
For professional claims only, place the NPI in the NM1 segment of loop 2310B
(Rendering Provider) qualified by an XX. For example:
NM1*82*1*RENDERING*PROVIDER****XX*1234567890
PRV*PE*ZZ*2585DFDF000X
Help for Mapping Paper Claims
For help mapping the fields on a paper CMS 1500 or UB04 claim form to the proper
positions in a HIPAA-compliant 4010 837, review UHIN’s standards:
CMS 1500
UB04
Status of Non-HIPAA-Compliant Claims
As a payer covered by HIPAA, we’re committed to being compliant with the EDI standards
for health care as established by the Secretary of Health and Human Services (HHS).
All provider transactions must comply with the UHIN standards —adopted by the state of
Utah — for use of electronic data interchange. You can review those standards
at http://www.uhin.org/pages/standards-specifications.php.
We’ll work with individual providers to help them become compliant.
We’ll continue to contact and work with each of our EDI trading partners to assess
their readiness, and we’ll help with the testing process. It’s our goal to maintain a
smooth flow of payments through effective use of EDI processing.
Eligibility Transactions (270 and 271)
Benefit and eligibility inquiries can be performed using UHIN Transactor (UHINt).
UHINt is an Internet-based product used to interface between a medical billing system
and UHINet (UHIN’s Internet portal). It can also be used to directly enter claims,
eligibility inquiries, etc. To access the information you’ll need to:
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Download the UHINt tool off www.uhin.org.
For more information about using UHINt, please contact UHIN at (801) 466-7705 ext. 200.
Using UHINt to send an eligibility inquiry (270):
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Login
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Click on Query, located on the left side of the screen
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Choose the tab called Eligibility (270)
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You will need the following details to access benefit information from UHINt:
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Payer Name – Deseret Mutual
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Patient’s Deseret Mutual ID Number
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Patient’s Last Name
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Patient’s First Name
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Patient’s Birth Date
The following benefits can be obtained through the 270 transaction:
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A member’s policy status (active or not active)
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If a member’s policy is not active, we’ll send the most recent beginning and end dates
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If a member’s policy is active, we’ll send the end date up to age 26 for dependents only
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In- and out-of-network benefit information
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Coinsurance percentage
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Copayment amount
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Annual deductible amount for family and individual, as well as the amount applied
to the deductible for the year
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Out-of-pocket annual amount for family and individual, as well as the amount applied
to the out-of-pocket for the year
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Annual visit limitations
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The number of remaining visits available
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COB information — we only return the carrier name and the primary record
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PCP information for Deseret Choice members living in Hawaii
If your practice management system also generates a 270, you may be able to receive
this information with a print/display feature directly into your practice management system.
How we Use the Unsolicited 277FE
We’ll generate a series of unsolicited 277 claims status front-end acknowledgements or 277FE.
The first series will report, on a claim-by-claim basis, information on all claims we’ve
received in a particular batch. This will be available on UHINet within one business day
of receipt. At this point the claims have not entered our processing system and we have
not taken legal responsibility for them.
The second series will report whether a claim has been accepted into our processing system
or rejected (with the reason why). This second series won’t match up claim-by-claim with
any original submitted batch and will most likely contain information on claims submitted
in various batches over various days. For claims that are accepted into our processing
system, we’ll include the Deseret Mutual Claim Number. This number can be used later
on in submitting a 276 Claim Status Request (either in a batch mode or real time).
We’re in the early development stages of preparing for 5010. We will provide more
information about 5010 as we get closer to implementation.