HIPAA EDI Companion Document


Introduction

Deseret Mutual is currently accepting HIPAA-compliant transactions through the Utah Health Information Network's UHINet product (see www.uhin.org).

We are currently accepting/generating the following HIPAA-compliant transactions:

  • 837 004010X098A1 (professional claim)
  • 837 004010X096A1 (institutional claim)
  • 270/271 004010X092A1 (eligibility - - both batch and real-time)
  • 276/277 004010X093A1 (claim status - - both batch and real-time)
  • 835 004010X091A1 (remittance)

In addition, for all claims submitted through UHINet, we are generating an unsolicited 277 claims status transaction (herein referred to as the 277FE or 277 Front End acknowledgement).  This is not a HIPAA-related transaction and is actually in a 004020 format (see www.uhin.org for the implementation guide; see "How we Use the Unsolicited 277FE" below for how Deseret Mutual uses this transaction).  This 277FE replaces and enhances the functionality of the 864 text message for relaying information on submitted claims.

All trading partners that are currently submitting version 003032 claims to Deseret Mutual are automatically set up in our data base for the submission of 004010 claims.  However, every trading partner must first submit test claims through UHINet before production claims can be submitted for payment.


Testing Procedures

All claims submitted through UHINet are initially routed to our test data base for analysis by our EDI staff.  No payment will be generated for these claims.  If you are currently sending us version 003032 claims through the old UHIN switch, you do NOT need to contact us before submitting test claims.  Your new version 004010 claims will automatically be sent to our testing data base.  We are expecting 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 received and contact you.  We will let you know either a) that no problems were encountered and we are ready to accept your claims in a production mode, or b) that there were some problems that need to be addressed before we can switch to a production mode.

(Note: if the claims submitted for the test are claims for which you expect payment, these claims need to be re-submitted once we have approved the switch to production.  We will NOT automatically migrate test claims to our production system.)

It has been our experience that the Testing Usage Indicator in the ISA segment is an unreliable indicator for routing claims.   Therefore, all trading partners are initially set up to have claims routed to our test data base regardless of the Usage Indicator.   Likewise, when a trading partner has been switched to production, all claims will be routed to our production data base.  If a trading partner wants to submit both test and production claims at the same time, please contact us and we will change our system to "honor" the T or P Usage Indicator in the ISA segment.

If you are not currently enrolled with Deseret Mutual for EDI submission, please contact a Provider Maintenance Representative at 1-800-777-3622 or (801) 578-5600 for enrollment.


The Deseret Mutual-assigned Provider Number
Dual use acceptance of the NPI  (October 2006 – May 22, 2007)

Deseret Mutual now accepts your National Provider Identifier (NPI) in conjunction with our commercial legacy number.

The NPI is a new single health-care provider identifier that replaces the provider identifier(s) you currently use, and must be used by all HIPAA covered entities.  The NPI will be federally mandated for use on May 23, 2007.   So you cannot send your current unique billing (commercial and government payer legacy) numbers in your electronic transactions after May 23, 2007.  If you don’t have your NPI now, it’s time to apply!

Applying for an NPI is easy.  Simply go to the National Plan and Provider Enumeration System (NPPES) website, https://nppes.cms.hhs.gov/NPPES/Welcome.do.   You must have your taxonomy code (specialty), which can be found at http://www.wpc-edi.com/codes/taxonomy.

If you need more information about NPIs, call UHIN at (801) 466-7705 ext 204, or visit the dedicated CMS web page (http://www.cms.hhs.gov/nationalprovidentstand).

If you have your NPI but have not yet given it to Deseret Mutual, please do so using one of the following methods:

  • Submit the NPI in your 837 transaction during the dual use period (October 2006 to May 22, 2007) with the commercial legacy number.
  • Forward your e-mail confirmation from NPPES (include your legacy/Deseret Mutual assigned provider number with your NPPES confirmation) to one of the following individuals:
  • For multiple providers, you may submit NPIs in an Excel spreadsheet, with information in the following order, to one of the individuals named above:
    • NPI
    • Tax ID
    • Group Name (if NPI is for the group not an individual)
    • Last Name
    • First Name
    • Middle initial
    • Date of Birth
    • Sex
    • Practice service location (Address 1)
    • Address 2
    • City
    • State
    • Zip (minimum 5 or maximum 9)
    • Phone
    • Legacy number

    • Deseret Mutual-Assigned Provider Number and NPI 837 Example

    We are expecting to find the Deseret Mutual-assigned provider number and NPI in at least one of three specific locations in the 004010 claim. 1) Loop 2010AA Billing Provider, 2) loop 2010AB Pay-To Provider, and 3) loop 2310B Rendering Provider.  If you do not know your Deseret Mutual-assigned number, please contact us.  This number is commonly referred to as the G33 or P33 number on professional claims (so named because it appears in Box 33 of the HCFA-1500 paper form - - G33 for the right side of box 33 and P33 for the left side of box 33).  Deseret Mutual uses the same number for both P33 and G33.  For facility claims, it is the number in box 51 of the UB92.

    In the examples below, the Deseret Mutual-assigned Provider Number is 0306 and the mock NPI is 1234567890.

    1. BILLING PROVIDER
      • Currently the DMBA assigned number can be placed in a REF segment of loop 2010AA (Billing provider) qualified by a G2.  For example:

        HL*1**20*1
        NM1*85*2*BILLING*PROVIDER****24*871234567
        N3*123 MAIN STREET
        N4*SALT LAKE CITY*UT*84111
        REF*G2*0306
      • During the dual use period (Oct 2006 – May 22, 2007), the NPI can be placed in the NM1 segment of loop 2010AA (Billing provider) qualified by an XX.   The DMBA-assigned number will remain in the REF segment.  An additional 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*G2*0306
        REF|EI|870000000
    2. PAY-TO PROVIDER
      • Currently the DMBA-assigned number can be placed in a REF segment of loop 2010AB (Pay-To Provider) qualified by a G2.  For example:

        HL*1**20*1
        NM1*87*2*PAY-TO*PROVIDER****24*871234567
        N3*123 MAIN STREET
        N4*SALT LAKE CITY*UT*84111
        REF*G2*0306
      • During the dual use period (Oct 2006 – May 22, 2007), the NPI can be placed in the NM1 segment of loop 2010AB (Pay-To Provider) qualified by an XX.  The DMBA-assigned number will remain in the REF segment.  An additional 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*G2*0306
        REF|EI|870000000
    3. RENDERING PROVIDER
      • Currently, for professional claims only, the DMBA-assigned number can be placed in a REF segment of loop 2310B (Rendering Provider) qualified by a G2.  For example:

        NM1*82*1*RENDERING*PROVIDER****24*871234567
        PRV*PE*ZZ*2585DFDF000X
        REF*G2*0306
      • For professional claims only during the dual use period, the NPI can be placed 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
        REF*G2*0306


    How we Use the Unsolicited 277FE

    Providers submitting claims to Deseret Mutual using the old UHIN switch are used to receiving an 864 text message within 1 working day reporting the number of claims received and the total dollar amount for those claims.  Under UHINet we will no longer generate an 864.   Instead we will 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 have received in a particular batch.   This will be available on UHINet within 1 business day of receipt.   At this point in time 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" will not match up claim-by-claim with any original submitted batch and most likely will contain information on claims submitted in various batches over various days.  For claims that are accepted into our processing system, we will 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).


    Help for Mapping Paper Claims

    The best source of help for determining how to map the fields on a paper HCFA-1500 or UB92 claim form to the proper positions in a HIPAA-compliant 4010 837, can be found by reviewing the standards provided by the Utah Health Information Network (UHIN).  Please consult the following URLs:

    CMS 1500

    UB04

    Status of Non-HIPAA-Compliant Claims After October 16, 2003

    As a payer who is a covered entity under HIPAA, Deseret Mutual is committed to being compliant with the EDI standards for health care as established by the Secretary of HHS.  Accordingly, we have been ready to accept (or send) the listed transactions for several months prior to the October 2003 deadline.  We are currently testing with several trading partners.

    Deseret Mutual recognizes that several of our trading partners who are currently submitting claims in a format prior to the HIPAA-mandated format will not be ready with the new format by the October 16 deadline.  In order to ensure the smooth flow of payments, Deseret Mutual will continue to accept transactions in the older format and will work with individual providers to help them become compliant.

    Deseret Mutual will continue to contact and work with each of its EDI trading partners to assess their readiness and assist with the testing process.  It is the goal of Deseret Mutual to maintain a smooth flow of payments through effective use of EDI processing.  It is our preference that providers continue to use the UHIN dial-up switch rather than drop to paper claims.  We will work towards compliance with each willing provider.

    Note: Deseret Mutual is not a HIPAA certification facility.   The testing process is in no way certifying that your transactions are HIPAA compliant.  Testing is done to ensure that trading partners meet our processing requirements for the appropriate transaction.

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