1. EDI 201 Advanced Concepts
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2. Terms and Acronym definitions
HIPAA - Health Insurance Portability and Accountability Act of 1996
CAQH - Council for Affordable Quality Healthcare
NACHA -  National Automated Clearing House Association
CCD/CCD+ - Cash Concentration or Disbursement 
ACH - Automated Clearing House
EFT – Electronic Funds Transfer
ERA – Electronic Remittance Advice
Trace# - EDI segment that the Health Plans put in both the ERA and the ACH CCD+ Addenda Record
IG – Implementation Guide
CG – Companion Guide

3. TRANSACTION TYPES X12 – 5010 CURRENT OFFICIAL STANDARD
837D Dental Claim
270/271 Eligibility
835/ERA/EFT Adjudication & Claim Payment
276/277 Claim Status

4. Topics for Today’s Session
7030 update (unofficial)
837 X12 (5010) Transaction Breakout
835/ERA

5. 7030 Update

6. 7030 Detail Cycle 1: September 1 through October 31, 2016
007030X334 Payroll Deducted and Other Group Premium Payment for Insurance Products (820)*
007030X345 Health Insurance Exchange Related Payments (820)
007030X333 Benefit Enrollment and Maintenance (834)*
007030X346 Health Insurance Exchange: Enrollment (834)
Cycle 2: October 1 through November 30, X329 Health Care Claim Status Request and Response (276/277)*
007030X330 Health Care Claim Acknowledgment (277CA)
007030X331 Health Care Claim Pending Status Information (277P)
007030X335 Implementation Acknowledgment for Health Care Insurance (999)
Cycle 3: November 1, 2016 through January 30, 2017
007030X322 Health Care Claim Payment/Advice (835)*
Cycle 4: February 1 through June 1, 2017  X323 Health Care Claim: Professional (837P)*
007030X324 Health Care Claim: Institutional (837I)*
007030X325 Health Care Claim: Dental (837D)*
007030X326 Health Care Service: Data Reporting (837R)

7. 7030 Detail
Cycle 5: September 1, 2017 through January 31, X327 Health Care Services Review Inquiry and Response (278)
007030X328 Health Care Services Review - Notification and Acknowledgment (278)
007030X342 Health Care Services Request for Review and Response (278)*
Cycle 6 Cycle 6 has been postponed, new start and end dates will be published when available.
007030X332 Health Care Eligibility/Benefit Inquiry and Information Response (270/271)*
Cycle 7 Cycle 7 has been postponed, new start and end dates will be published when available.
007030X321 Application Reporting for Insurance (824)
007030X340 Health Care Claim Request for Additional Information (277RFI)
007030X341 Additional Information to Support a Health Care Claim or Encounter (275)
007030X343 Additional Information to Support a Health Care Services Review (275)

8. What a normal 837D (claim) looks like
ST*837*3456*005010X224~BHT*0019*00*0123* *1023*CH~NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE* ~NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~HL*1**20*1~NM1*85*2*DENTAL ASSOCIATES*****XX* ~N3*234 SEAWAY ST~N4*MIAMI*FL*33111~REF*EI* ~NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8* *M~NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8* *M~LX*1~SV3*AD:D2150*100****1~TOO*JP*12*M:O~LX*2~SV3*AD:D1110*50****1~SE*31*3456~

9. Common Segment Definitions
HL: Hierarchical Loop – Illustrates what level we’re at
ST: Transaction Set Header (“Starting Transaction”)
SE: Transaction Set Trailer (“Stuff Ended”)
NM1: Name (“NaMe”) - Can be a Human or Non-Human), see NM1 list for more
REF: Identifier (“REFerence”) – Can identify almost anything, see IG for details
N3: Address - Line 1 & 2
N4: City/State/Zip/Country
There are more, but these are the common ones…

10. Claim 837D Breakout – Part 1 HEADER ST*837*3456*005010X224~
ST TRANSACTION SET HEADER
BHT*0019*00*0123* *1023*CH~
BHT TRANSACTION SET HIERARCHY AND CONTROL INFORMATION
1000A SUBMITTER
NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~
NM1 SUBMITTER
PER*IC*JERRY*TE* ~
PER SUBMITTER EDI CONTACT INFORMATION
1000B RECEIVER
NM1*40*2*INSURANCE COMPANY XYZ*****46*66783JJT~
NM1 RECEIVER

11. Claim 837D Breakout – Part 2 2000A BILLING PROVIDER HL LOOP
HIERARCHAL LEVEL 1
HL*1**20*1~
2010AA BILLING PROVIDER
NM1*85*2*DENTAL ASSOCIATES*****XX* ~
NM1 BILLING PROVIDER NAME
N3*234 SEAWAY ST~
N3 BILLING PROVIDER ADDRESS
N4*MIAMI*FL*33111~
N4 BILLING PROVIDER LOCATION
REF*EI* ~
REF BILLING PROVIDER'S TAX IDENTIFICATION

12. Claim 837D Breakout – Part 3 2010BB SUBSCRIBER/PAYER
NM1*PR*2*INSURANCE COMPANY XYZ*****PI*66783JJT~
NM1 PAYER'S NAME
2000C PATIENT'S HL LOOP
HL*3*2*23*0~
HIERARCHAL LEVEL 3
PAT*19~
PAT PATIENT INFORMATION
2010CA PATIENT
NM1*QC*1*SMITH*TED~
NM1 PATIENT'S NAME
N3*236 N MAIN ST~
N3 PATIENT'S ADDRESS
N4*MIAMI*FL*33413~
N4 PATIENT'S CITY
DMG*D8* *M~
DMG PATIENT DEMOGRAPHIC INFORMATION

13. Claim 837D Breakout – Part 4 2300 CLAIM
CLM* *150***11:B:1*Y*A*Y*I~
CLM HEALTH CLAIM INFORMATION
DTP*472*D8* ~
DTP DATE - SERVICE DATE
REF*D9* ~
REF VAN CLAIM NUMBER
2310B RENDERING PROVIDER
NM1*82*1*KILDARE*BEN****XX* ~
NM1 RENDERING PROVIDER’S NAME
PRV*PE*PXC*1223G0001X~
PRV RENDERING PROVIDER INFORMATION

14. Claim 837D Breakout – Part 5 2400 SERVICE LINE LX*1~
LX SERVICE LINE NUMBER
SV3*AD:D2150*100****1~
SV3 DENTAL SERVICE
TOO*JP*12*M:O~
TOO TOOTH NUMBER/SURFACES
LX*2~
SV3*AD:D1110*50****1~
TRAILER
SE*31*3456~
SE TRANSACTION SET TRAILER

15. Using Electronic Remittance Advice for Fun and Profit
835/ERA
Using Electronic Remittance Advice for Fun and Profit
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16. What is an 835? Electronic version of an EOB
Contains claim payment, denial, and pended information
An important part of a balanced revenue cycle – ZERO Trans-Fat!
The 835 is basically an electronic version of the EOB. It contains all the information related to a payment, i.e. claims payment, denial and pended information.

17. Revenue Cycle
I was thinking of letting Tom walk through this diagram since I believe it came from him. Thoughts?

18. What is an 835 made of?
ISA*00* *00* *01* *30* *120313*0406*^*00501* *0*P*:~
GS*HP* * * * *13521*X*005010X221A1~
ST*835*0019~
BPR*I*115*C*ACH*CTX*01*03125*DA* *127586**01*121358*DA*149101* ~
TRN*1* *127586~
REF*EV* ~
DTM*405* ~
N1*PR*INSURANCE COMPANY OF NEBRASKA~
N3*311 DAISY CTR~
N4*OMAHA*NE*68144~
PER*BL*DENNIS RITCHIE*TE* *EX*123~
N1*PE*DOWNTOWN DENTAL*XX* ~
N3*P.O. BOX ~
N4*ST. LOUIS*MO* ~
REF*PQ* ~
REF*TJ* ~
LX*1~
CLP* *1*260*115*50*12* *11*1~
NM1*QC*1*PATIENT*DAWN~
NM1*IL*1*SUBSCRIBER*YUNA****MI*W ~
NM1*82*1*DOCTOR*SAMANTHA*D***XX* ~
REF*1L* GT~
REF*CE*Standard Dental PPO NET 85789~
DTM*232* ~
DTM*233* ~
DTM*050* ~
PER*CX*MAUDE LEBOWSKI*TE* ~
AMT*AU*260~
SVC*AD:D7210*260*115**1~
DTM*472* ~
CAS*PR*1*50~
CAS*CO*45*95~
REF*6R* ~
AMT*B6*165~
SE*33*0019~
GE*341*13521~
IEA*1* ~
This slide identifies the different loops, segments and data elements in an 835 transaction. We will walk through each of these loops during this session and answer any question you may have. Please remember that we have an 835 Town Hall meeting and that is were we plan to get into a more involved discussion on some of the current issues the industry encounters today with the 835 transaction.

19. “Envelope” section
ISA*00* *00* *01* *30* *120313*0406*^*00501* *0*P*:~
GS*HP* * * * *13521*X*005010X221A1~
ST*835*0019~ .
SE*35*0019~
GE*341*13521~
IEA*1* ~
This slide identifies the header and trailer enveloping of the 835 transaction. The segments are standard in all of the X12 HIPAA transactions.

20. Begin Payment Record
BPR*I*260*C*ACH*CTX*01*03125*DA* *127586**01*121358*DA*149101* ~
TRN*1* *127586~
The BPR segment is for identifying the financial information. It tells if the 835 is accompanied with the payment or if this is payment only, remittance only or notification only. Typically, we see an I – Remittance Information Only in this field. It provides the total dollar amount of the payment and tell us if it is a check or EFT. If the payment is EFT, this segment also provides the information as to what financial institution is used by the payee. The TRN segment is used to uniquely identify the 835 to aid in re-associating the payment and remittances that have been sent separate. The check number or EFT trace number is sent in the TRN02 and the TRN03 is the payer’s TIN. Note this TIN must always be preceeded the payer’s TIN, i.e.,

21. Receiver Identification & Production Date
REF*EV* ~
DTM*405* ~
The REF segment here is to identify the entity actually receiving the 835, i.e., clearinghouse/billing service. This is typically the actual Trading Partner receiving the 835 transaction. This is not a required segment and it is as the discretion of the sender of the 835 transaction. The DTM segment is to identify the cut off date of the adjudication system remittance run. For example, if the claim adjudication cycle was completed on a Thursday, but the 835 wasn’t produced till Friday, this segment should include the Thursday date.

22. Payer Details N1*PR*INSURANCE COMPANY OF NEBRASKA~ N3*311 DAISY CTR~
N4*OMAHA*NE*68144~
This loop identifies the payer name and address from which the 835 is being sent.

23. Payee/Provider Details
PER*BL*DENNIS RITCHIE*TE* *EX*123~
N1*PE*DOWNTOWN DENTAL*XX* ~
N3*P.O. BOX ~
N4*ST. LOUIS*MO* ~
REF*PQ* ~
REF*TJ* ~
Next we get into the Payee/Provider information. This loop contains the details on who this payment is being made to. The N104 contains the NPI of the payee. The address loops are standard. The REF segments here allow for additional identification number on the transaction. The REF is situational and may be provided at the senders discreation. In this case, you see the PQ – Payee Identification and TJ – Federal Tax Identification qualifier used.

24. Transaction Set Line Number
LX*1~
The LX segment is used to provide a looping structure and logical grouping of claim payment information.

25. Claim-Level Payment Information
CLP* *1*260*115*50*12* *11*1~
Here is where the claim level information begins. It is important that the CLP01 contains the patient control number that was sent in on the 837D transaction as this data element is the primary key for posting remittance information in the providers’ databases. In cases where paper claims are included on the 835 and there is no patient control number, a payer may use a specific number to identify them as such. We at UCD always use a zero in this data element in this situation. These types of business requirements should be outlined in the payer’s EDI Companion Guide. The CLP also contains the claim status code, the total claim charge, the total payment amount, the patient responsibility amount, type of insurance, the payer claim number, place of service, and claim frequency code. Zero is the default value in the guide when a value is not sent (ie paper claim).

26. Patient/Provider Identification
NM1*QC*1*PATIENT*DAWN~
NM1*IL*1*SUBSCRIBER*YUNA****MI*W ~
NM1*82*1*DOCTOR*SAMANTHA*D***XX* ~
These segments represent the Patient, Subscriber and Rendering Provider as sent on the original claim. NM1 segments contain an identifier for the entity (QC- Patient, IL – Subscriber, 82 – Rendering Provider), followed by Last Name, First Name and Identity (MI- MemberID, XX – NPI)

27. Group and Contract Codes
REF*1L* GT~
REF*CE*Standard Dental PPO NET 85789~
These REF segments represents identifications in the Payer’s system. REF02 with an 1L qualifier is the Group number

28. Service Dates DTM*232*20130219~ DTM*233*20130219~
The DTM segment represents a date. In this case, these claim level dates are representative of the start and end of the procedure dates (232 Start, 233 end) and should reflect what was sent on the original claim. If the start is sent but the end is not then the assumption is that the end is equal to the start.
For predeterminations, where there is no service date, the value of DTM02 must be

29. Date Claim Received DTM*050*20130220~
This DTM represents the date the claim was received into the adjudication system at the payer

30. Technical Department Contact
PER*CX*MAUDE LEBOWSKI*TE* ~
The PER segment represents a way to contact the identified party. In this case there is a name and phone number and the only value of the type of contact allowed is CX which stands for the Payer’s Claim Office.

31. Coverage Amount AMT*AU*260~
This AMT segment allows the payer to convey information about the payments but is not used in balancing. AU stands for Coverage Amount. “T” would stand for Tax.

32. Claim Detail Reporting
SVC*AD:D7210*260*115**1~
DTM*472* ~
CAS*PR*1*50~
CAS*CO*45*95~
SVC is a reflection of the line item sent in the 837 in that it identifies the Procedure Code (SVC01), submitted item charges (SVC02) and the quantity (SVC05). It also contains the total amount to be paid on that line (SVC03).
The DTM is the line level date of service and is required if the claim level is not sent. Future dates of service are allowed and if the line is related to a predetemination, then the value of is used.
CAS Segment (Adjustment segment) - These segments give the details of the adjustments that make up the difference between the amount submitted (SVC02) and the amount paid (SVC03). The segment has a category/class of reasons (CAS01) Known as a “Claim Adjustment Group Code” and the specific claim adjustment reason code (CARC in CAS02), the dollar amount (positive value reflects a reduction of payment) and a quantity (not shown) and can be repeated 6 times for different reasons in each class.
The Group Codes take on 1 of 4 values
1) CO Contractual Obligations - Use this code when a joint payer/payee agreement or a regulatory requirement has resulted in an adjustment.
2) OA Other adjustments - Avoid using the Other Adjustment Group Code (OA) except for business situations described in front matter.
3) PI Payor Initiated Reductions - Use this code when, in the opinion of the payer, the adjustment is not the responsibility of the patient, but there is no supporting contract between the provider and the payer (i.e., medical review or professional review organization adjustments).
4) PR Patient Responsibility
Claim Adjustment Reason Codes (CARCs)
Values are available on the Washington Publishing website.
In this example the first CAS segment has a value of 1 which means “Deductible Amount” and the second CAS segment has a value of 45 which means “Charges exceed your contracted/ legislated fee arrangement.”

33. Line Item Control Number
REF*6R* ~
Value in this segment is a reflection of the line item control number sent in the original 837 claim. Identification of the line to post against does not contain all information sent on the claim (ie tooth, quadrant). A paper claim will generally not have a this segment sent.

34. Service Supplemental Amount
AMT*B6*165~
Another non balancing related segment to identify information related to line level processing. B6 in this case means
Allowed - Actual
Allowed amount is the amount the payer deems payable prior to considering patient responsibility.

35. Balancing an 835 3 levels of balancing: Payment Claim Service Line
A payment typically contains multiple claims. Each claim usually has multiple service lines. A valid 835 file will have correct totals between these 3 levels.

36. Payment Balancing BPR*I*491.4*C*CHK************20130314~
CLP* *1*125*67**12* *11*1~
SVC*AD:D0150*70*36**1~
CAS*CO*45*34~
SVC*AD:D0220*30*17**1~
CAS*CO*45*13~
SVC*AD:D0230*25*14**1~
CAS*CO*45*11~
CLP* *1*135*36**12* *11*1~
SVC*AD:D0210*65*0**1*AD:D0274~
CAS*CO*97*65~
CLP* *1*1100*362.4*291.6*12* *11*1~
SVC*AD:D5211*1100*362.4**1~
CAS*PR*1*50**2*241.6~
CAS*CO*45*446~
CLP* *1*70*26**12* *11*1~
SVC*AD:D0120*70*26**1*AD:D0150~
CAS*CO*45*44~
Here is an example of a payment, stripped down to the Claim-Level CLP segments, and the Service Level SVC & CAS segments. Over the next few slides, we will review how to balance between those levels.

37. Payment Balancing
BPR*I*491.4*C*CHK************ ~
CLP* *1*125*67**12* *11*1~
CLP* *1*135*36**12* *11*1~
CLP* *1*1100*362.4*291.6*12* *11*1~
CLP* *1*70*26**12* *11*1~
The BPR02 needs to be a total of all of the CLP04 elements contained under the payment:
491.4 =
Here is an example of a payment, stripped down to the Claim-Level CLP segments. The BPR02 needs to be a total of all of the Claim-Level Payments at the CLP04s under the Payment in question.

38. Claim Balancing CLP*9833798*1*125*67**12*13067219102*11*1~
SVC*AD:D0150*70*36**1~
CAS*CO*45*34~
SVC*AD:D0220*30*17**1~
CAS*CO*45*13~
SVC*AD:D0230*25*14**1~
CAS*CO*45*11~
67 =
125 =
67 = 125 – ( )
Charge Amount
Paid Amount
Adjustment(s)
The Total Charges in CLP03 must be a summary of the Charges in each Line Item at SVC02. The same goes for the Paid Amount in CLP04 and the SVC03s. Finally, the total of all of the charges must match the total of all of the Line-Item payments plus the Line Item adjustments.

39. Claim Balancing (with Claim-Level Adjustments)
CLP* *1*260*115*50*12* *11*1~
CAS*OA*101*95~
260 =
Charge Amount
Paid Amount
Adjustment(s)
If you have an 835 that reports Claim-level items, but no Line-item level items, you will find that Adjustments are reported at the claim level. In this example, the Charge Amount is equal to the Paid Amount, plus any Adjustments that are reported.

40. Service Line Balancing
SVC*AD:D7210*260*115**1~
CAS*PR*1*50~
CAS*CO*45*95~
0 = 260 – 115 – 50 – 95
(or)
0 = 260 – 115 – ( )
Charge Amount
Paid Amount
Adjustment(s)
The Paid Amount (in green) is equal to the Charge Amount (in Blue) minus any Adjustments (in Red).

41. Reporting Bundled Charges
CLM*44926*277***11:B:1*Y*A*Y*Y
SV3*AD:D1110*68****1
SV3*AD:D0120*45****1
SV3*AD:D0272*39****1
SV3*AD:D0330*125****1
REF*6R*X
CLP^44926^1^277^119^^12^ ^11^1
SVC^AD>D1110^68^44^^1
SVC^AD>D0120^45^20^^1
SVC^AD>D0210^39^0^^1^AD>D0272
SVC^AD>D0210^125^55^^1^AD>D0330
Original Code 1
Original Code 2
Bundled Code returned
Amount paid
The provider sent a D0272 (2 Bitewings) and a D0330 (Pano). The payer bundled these codes, and returned a D0210 (Full Mouth Series).

42. Additional Segments Remittance Advice Remark Code: LQ✽HE✽12345~
Provider Level Adjustment:
PLB✽ ✽ ✽CV: ✽-1.27~
Some other segments are used and will be referred to frequently in discussions. These include:
The LQ segment is used in conjunction with a CAS02 level element for additional information needed to allow a provider to understand the reason for the adjustment. The segment describes a Remittance Advise Reason Code (RARC) and the list of RARC codes can be found on the Washington Publishing website.
CORE operating rules have put into place reasonable combinations of CARC and RARC codes to be used. More discussion will be had in other forums.
The PLB segment is one of those frequently used but seldom understood segments used to adjust payments outside of the specific claims identified in the rest of the document. It can be used for a number of reasons and has elements for reference numbers, categories and dollar amounts. This is probably one of the most misunderstood segments.

43. Speaker Contact Information
Eric Kirnbauer
Tesia Clearinghouse, LLC
Tom Mort
DentalXChange
Ext. 115