1. Lesson 4 Reading 837 Error Reports and Making Corrections

2. 2 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

3. 3 What Does It Mean For You? Application Coordinator: “Once you understand the 837, it’s going to make your job more efficient.”

4. 4 Transaction Set Sections Overall data stream of 837 is called a Transaction Set Transaction Set contains sections; each section provides specific kind of information Transaction Set sections: –Transaction Header –Billing Provider Detail – Subscriber Detail – Patient Detail – Claim Detail – Transaction Trailer

5. 5 Data Segments Every section of Transaction Set contains data segments Segments begin each line of detail Segments are 2-3 alpha characters Here segments are in bold ISA*00* *00* *ZZ*000001063 *ZZ*NDDHSMED *040812*1504*U*00401*000101537*1*P*: GS*HC*000001063*NDDHSMED*20040812*1504*101537*X*004010X096A1 ST*837*0001 BHT*0019*00*101537*20040812*1504*CH REF*87*004010X096A1

6. 6 Data Elements Each segment contains data elements – Similar to data provided by each individual Form Locator position on UB-92 or HCFA 1500 Number of elements varies depending on segment’s purpose Data elements separated by asterisks In this example, ST segment has 2 elements; BHT segment has 6 elements ISA*00* *00* *ZZ*000001063 *ZZ*NDDHSMED *040812*1504*U*00401*000101537*1*P*: GS*HC*000001063*NDDHSMED*20040812*1504*101537*X*004010X096A1 ST*837*0001 BHT*0019*00*101537*20040812*1504*CH REF*87*004010X096A1

7. 7 Counting Data Elements To correct errors in an 837, you need to know how to count data elements Element counts begin to the right of the segment; elements separated by asterisk In this example: – ST01 is “837” (first set of data between asterisks) – BHT03 is “101537” (third set of data between asterisks) ISA*00* *00* *ZZ*000001063 *ZZ*NDDHSMED *040812*1504*U*00401*000101537*1*P*: GS*HC*000001063*NDDHSMED*20040812*1504*101537*X*004010X096A1 ST*837*0001 BHT*0019*00*101537*20040812*1504*CH REF*87*004010X096A1

8. 8 Quick Reference Guide Shows typical billing scenario and how it looks when presented in 837 format – 837 data string is broken out line-by-line so you can see the loops, segments, and data elements Explains how to convert 837 file into lined item that is easier to troubleshoot – When viewed on screen, 837 file is one long data stream – Can be very difficult to read

9. 9 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

10. 10 Three Different Guides/Addenda Three versions – Institutional: 004010X096 – Professional: 004010X098 – Dental: 004010X097 Use correct Implementation Guide for batch type – Segments and data elements may be different in each

11. 11 What Elements Are Required in a Segment? Find segment listed in appropriate Implementation Guide’s Table of Contents Go to given page You will find: – Loop name – Whether segment is required or situational – Data elements required in segment – How to enter data elements – Correct order of elements

12. 12 Required or Situational? Loops, segments, and elements can be required or situational “Required” is mandatory – Claim will be rejected if this information is not included Situational information – Information may or may not be needed – Depending on the claim’s criteria Each Implementation Guide explains what information is required and what is situational

13. 13 Loops Are Important Loop is a section of data on 837 Examples –Submitter Name loop –Billing Provider Name loop –Claim Level Information loop Similar to data stored in Patient Registration or Fileman files

14. 14 What Loops Tell You Where to find a data segment Some data segments repeat –E.g., address line or N3 Billing Provider address Subscriber address Patient address But each address line will be in a different loop – Segment N3 of loop 2010AA has Billing Provider address – Segment N3 of loop 2010BA has Subscriber address

15. 15 Loop Numbering Loop number is four digits Number is often followed by one or two alphabetical characters – 2400 – 2010BB

16. 16 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

17. 17 Types of Error Reports 997 Functional Acknowledgement – Is the generally recognized response to 837 electronic transaction – Indicates whether file was accepted or rejected Other error report formats – Arizona Medicaid uses format called 824 – Other formats used by clearinghouses and private insurers

18. 18 How to Retrieve Error Report Instructions for retrieving error reports can be found in Companion Guide If you are working with a clearinghouse, they will provide instructions

19. 19 997 Functional Acknowledgement Data elements are counted in same way they are for an 837 file 997 format somewhat different from 837 format – Segments after header all begin with AK

20. 20 If File Is Accepted … If 837 file passed, it contains an “A” for “accepted” in first element of AK5 and AK9 segments –Files that have only AK5 and AK9 segments are error free; no more attention is needed ISA*00* *00* *ZZ*NDDHSMED *ZZ*000001063 *040812*1717*U*00401*000000011*0*P*> GS*FA*NDDHSMED*000001063*20040812*1717*9*X*004010X09 6A1 ST*997*0001 AK1*HC*101537 AK2*837*0001 AK5*A (Accepted File) AK9*A*1*1*1 (Accepted File) SE*6*0001 ST*997*0002

21. 21 If File Is Rejected … If 837 file is rejected, it contains an “R” for “rejected” in AK5 and AK9 segments Only rejected files display AK3 and AK4 segments AK3 and AK4 segments occur for each error found – AK3 and AK4 segments on 997 report show user the location (loop, segment, element, line) of the error on the matching 837 file

22. 22 997 Showing Rejected File ISA*00* *00* *ZZ*NDDHSMED *ZZ*000001063 *040812*1717*U*00401*000000011*0*P*> GS*FA*NDDHSMED*000001063*20040812*1717*9*X*004010X096A1 ST*997*0001 AK1*HC*101542 AK2*837*0001 AK3*DTP*242*2300*8 AK4*03*1251*8*20040419- AK3*DTP*253*2300*8 AK4*3*1251*8*20040406- AK5*R*5 (Rejected File) AK9*R*1*1*0 (Rejected File) SE*10*0002 ST*997*0003

23. 23 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

24. 24 Match Rejecting 997 to 837 File Some key things to learn to look for: –Batch number –Type of file –Dates and times

25. 25 Batch Number 837 is assigned individual batch number when batch is created Corresponding 997 file will contain same batch number Find batch number –On 837 file, BHT03 contains batch number –On 997 file, AK102 contains batch number

26. 26 Type of File On both 837 and 997, ST01 identifies the type of file (837 or 997) Files can also be identified by alphanumeric code that corresponds to Implementation Guides –Institutional (…096) –Professional (…098) –Dental (…097)

27. 27 Dates and Times Date and time of file transmissions is stored in Header elements of each file This information can be used to identify file batches

28. 28 This 837 and This 997 Match ISA*00* *00* *ZZ*000001063 *ZZ*NDDHSMED *040812*1504*U*00401*000101537*1*P*: GS*HC*000001063*NDDHSMED*20040812(Date)*1504(Time)*101537*X *004010X096A1(Institutional) ST*837*0001 (Transaction Type) BHT*0019*00*101537(Batch Number)*20040812(Date)*1504(Time)*CH REF*87*004010X096A1(Institutional) ISA*00* *00* *ZZ*NDDHSMED *ZZ*000001063 *040812*1717*U*00401*000000011*0*P*> GS*FA*NDDHSMED*000001063*20040812(Date)*1717(Time)*9*X*0040 10X096A1 (Institutional) ST*997*0001 (Transaction Type) AK1*HC*101537(Batch Number) AK2*837*0001

29. 29 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

30. 30 Reasons for Errors Errors can result from one or more of following: –Incorrect formats –Missing information –Incomplete information See Quick Reference Guide for list of common data errors that cause an 837 claim to be rejected

31. 31 AK3 and AK4 Segments on 997 AK3 and AK4 segments show user location of error on matching 837 file – Loop – Segment – Data element – Line Combination of AK301 and AK401 show segment and element where error is found on 837 file

32. 32 997 Rejected File Example shows loop number, error segment, error element, line number, and data that needs to be corrected ISA*00* *00* *ZZ*NDDHSMED *ZZ*000001063 *040812*1717*U*00401*000000011*0*P*> GS*FA*NDDHSMED*000001063*20040812*1717*9*X*004010X096A1 ST*997*0001 AK1*HC*101542 AK2*837*0001 AK3*DTP(Error Segment)*242(Line Number)*2300(Loop Indicator)*8 AK4*03(Error Element)*1251*8*20040419-(copy of data in error) AK3*DTP(Error Segment)*253(Line Number)*2300(Loop Indicator)*8 AK4*03(Error Element)*1251*8*20040406- AK5*R*5 (Rejected File) AK9*R*1*1*0 (Rejected File) SE*10*0002 ST*997*0003

33. 33 To Identify Error and Error Reason You must use HIPAA Implementation Guide and 837 to identify error and reason for error For process to follow, see steps and example in Quick Reference Guide

34. 34 Lesson 4 Topics 837 Data Layout Get to Know HIPAA Implementation Guides and Addenda Error Report Match 837 and 997 Files Find Errors Correct Errors and Resubmit Batch

35. 35 Correct Error in RPMS 837 file contains multiple claims run together You must locate claim number for problem claim in order to make correction For process to follow, see steps in Quick Reference Guide

36. 36 Recreate and Resubmit Batch Once all errors identified and corrected: – Recreate batch(es) – Resubmit files to insurer in next submission Process for recreating batches remains unchanged Remember that changes made to claims will not reflect on new 837 transmission unless batch was recreated prior to transmitting new file

37. 37 What Does It Mean For You? Assistant Site Manager: “You get familiar with what the errors are when you see them.”

38. 38 Tips Process will speed up as you become more acquainted with 837 and 997 files and with HIPAA Implementation Guides Error correction process is not simple but it can be mastered –Some sites have found it expedient to designate one person to correct all errors

39. 39 Tips (cont’d) Filename for batch cannot be more than 16 characters –Your trading partner’s Companion Guide may have naming conventions that partner wants to use Each recreated batch gets new RPMS number Make sure to only include corrected claims in recreated batch

40. 40 Tips (cont’d) Monitor error reports carefully – Check every batch in a report – Resubmit all errors – Until claim is submitted correctly, insurer has no record of the claim If 20 claims are rejected for one patient, it could be as simple as a name entered wrong in one place – Error must be corrected at source as well as on claim so that it doesn’t repeat

41. 41 Tips (cont’d) Know differences between insurers when resubmitting previously rejected claims – Medicare: Only rejected claims do not pass. Only resubmit rejected claims, not entire batch. – Medicaid: Any rejected claim causes entire batch to fail. Correct rejected claim(s); recreate and resubmit entire batch. – Private Insurance: Insurer specific. Ask each insurer how they will process files with rejects (e.g.,will entire batch fail or only rejected claims?)

42. 42 What Does It Mean For You? Applications Coordinator: “What I like about the 837 is the turnaround.”

43. 43 Lessons Learned Learn 837 data layout Get to know Implementation Guides and Addenda Learn how to read error report Match 837 and 997 files Find errors Correct errors and resubmit batch