835 Health Care Claim Payment Advice
Contents
1. provided if submitted Qualifier 2400 REFO1 used 837 Professional if submitted on the 837 Page 19 of 28 PGBA 835 Companion Guide X12 Loop ID Reference Codes Notes Comments ame this must be returned on the remittance pe Code to qualify amount 2110 AMT01 Ada Must equal and is provided in certain Allowed Actual situations if available Must use Code List HE Claim Payment Code identifying a 2110 001 Qualifier Code Remark Codes code specific industry code source 411 Remittance list Remark Codes Page 20 of 28 PGBA 835 Companion Guide Table 5 Summary X12 Loop ID Reference implementation Codes Notes Comments 2110 Must equal IR Internal Revenue Service Withholdings L6 Interest Owed Used for the interest paid on claims in the 835 Supports the related Provided only if a PLB03 1 adjustments where provider level PLBO5 1 AMTO is equal to I adjustment It 7 1 Adjustment Interest indicates the reason PLBO9 1 Reason Code WO Overpayment for a debit or credit PLB11 1 j Recovery Used for the memo or adjustment PLB13 1 recovery of previous to invoice debit or overpayment See IG Guide for information about balancing against a provider refund 72 Authorized Return This is the provider refund adjustment CS Adjustment credit memo or payment Page 21 of 28 PGBA 835 Companion2. Page 16 of 28 PGBA 835 Companion Guide Table 5 Detail X12 Loop ID Reference imp ne anon Codes Notes Comments The following codes are sent Identifies the status of an 1 Processed as entire claim as assigned 2100 CLPO2 Claim Status Primary by the payer claim review Code 2 Processed as organization or re pricing Secondary organization 3 Processed as Tertiary19 Code identifying the type of claim For many providers to electronically post the 77 835 remittance data to 2100 CLP06 Must use their patient accounting CH CHAMPUS systems with human intervention a unique provider specific insurance plan code is needed ICN Example Claim number format on 2100 CLP07 claim 835 3301 1 1 00 835 different from claim 837 3301X1KC10000 number on 837 Claim This segment is not used Adjustment or provided adjustments eae ae Claim Payment are reported at the Information service level Required if the patient ID Must use is known or was reported Patient Name on the health care claim HN Health Insurance Used for identification 2100 NM108 Claim Number code and under most spi COPIE circumstances this Number Note If either NM108 or element should be sent 109 is present then Should be same as MI if the other is required patient is the subscriber Insured Name T 2100 NM102 Entity Type Must use Code qualifying the type a of entity Qualifier 1 Person
3. Page 17 of 28 PGBA 835 Companion Guide X12 Loop ID Reference Tp Codes Notes Comments Must use Used for identification Insured Name Member code of the subscriber Identification Identification Under most 2100 ne Code Qualifier circumstances this Subscriber ID Note If either NM108 or element should be sent NM109 is present then the other is required Must equal Code designating the Senice Provider FI Federal N system method of code Identification structure used for 2100 N108 Number Identification Code 67 Gode Qualifier National Provider Code is provided if Identifier submitted Other Claim m Related Id Must equal 2 2100 REFO1 Reference EA Medical Record tovidod Tf avallabls Identification Identification Number P Qualifier 232 Claim period start Date Time date Code specifying type of 2100 DTMO1 Qualifier 233 Claim period end date Statement Date date Date Time When the patient is not a DEERS does not eligible for coverage the Qualifier oe 2100 DTMO1 Coverage maintain the history situational segment DTM Expiration Date needed to determine Coverage Expiration expiration of coverage Date on Loop 2100 will not be sent F5 Patient Amount Code to qualify the Amount Gualifiar Paid Use to report the amount and is provided 2100 01 Coda amount the patient has in certain situations already paid
4. DTM 050 20131129 AMT AU 768 56 SVC NU gt 0250 26 20 8 4 DTM 472 20131122 CAS CO 45 5 2 AMT B6 20 8 SVC HC gt 81001 63 25 3 85 0307 1 DTM 472 20131122 CAS CO 45 59 4 AMT B6 3 85 SVC HC274020 389 47 11 0320 1 DTM 472 20131122 CAS OA 96 341 89 AMT B6 47 11 SVC HC gt 99283 gt 25 87 1 696 8 0450 1 DTM 472 20131122 CAS CO 45 174 2 Page 24 of 28 PGBA 835 Companion Guide AMT B6 696 8 LX 8 01293494 1 882 5 600 1 105 9 3333 116 00 13 1 NM1 QC 1 TEST8 DALIS L HN CH01293494 NM1 IL 1 TEST8 DEJUAN L MI 888888888 REF EA 970687223 DTM 050 20131129 AMT AU 706 SVC NU gt 0250 1 1 5 7 82 2 DTM 472 20131123 CAS CO 45 2 3 CAS PR 2 1 38 AMT B6 9 2 SVC HC gt 99283 87 1 592 28 0450 1 DTM 472 20131123 CAS CO 45 174 2 CAS PR 2 104 52 AMT B6 696 8 LX 9 CLP CHO01293890 1 194 20 82 5 21 CH 3333X1 16G 00 13 1 NM1 QC 1 TEST9 BRENNAN D HN CH01293890 NM1 IL 1 TEST9 RUSSELL R MI 999999999 REF EA 980435490 DTM 050 20131129 AMT AU 26 03 SVC HC gt 73090 gt RT 194 20 82 0320 1 DTM 472 20131125 CAS OA 96 167 97 CAS PR 2 5 21 AMT B6 26 03 LX 10 CLP CH01293546 1 1084 0 CH 3333X1 16M 00 13 1 NM1 QC 1 TEST10 DANIEL O HN CH01293546 NM1 IL 1 TEST10 DANIEL O MI 101010101 REF EA 970762786 DTM 050 20131129 SVC HC gt 99283 87 1 0 0450 1 DTM 472 20131120 CAS OA 96 871 SVC HC gt 93005 gt TC 213 0 0730 HC gt 93005 1
5. DTM 472 20131120 CAS OA 96 213 LX 11 CLP CH01293430 1 1237 727 96 181 99 CH 3333X1 16N 00 13 1 NM1 QC 1 TEST11 ANTONIO Q HN CH01293430 NM1 IL 1 TEST11 ANTONIO Q MI 111111111 REF EA 970492977 DTM 050 20131129 AMT AU 909 95 SVC NU 0250 246 157 44 1 DTM 472 20131122 CAS CO 45 49 2 CAS PR 2 39 36 AMT B6 196 8 SVC HC294640 120 13 08 0412 1 DTM 472 20131122 CAS CO 45 103 65 CAS PR 2 3 27 AMT B6 16 35 SVC HC gt 99283 87 1 557 44 0450 1 DTM 472 20131122 CAS CO 45 174 2 Page 25 of 28 PGBA 835 Companion Guide CAS PR 2 139 36 AMT B6 696 8 LX 12 CLP CHO01293515 1 316 75 31 32 CH 3333X1168 00 13 1 NM1 QC 1 TEST12 AIDEN J HN CH01293515 NM1 IL 1 TEST12 MATTHEW J MI 123456789 REF EA 970736487 DTM 050 20131129 AMT AU 31 32 SVC HC gt 36415 22 75 0 0301 1 DTM 472 20131123 CAS CO 97 22 75 SVC HC284439 133 10 94 0301 1 DTM 472 20131123 CAS CO 45 122 06 AMT B6 10 94 SVC HC gt 84443 161 20 38 0301 1 DTM 472 20131123 CAS CO 45 140 62 AMT B6 20 38 LX 13 CLP CHO01288946 1 9072 25 890 56 CH 83333X146R 00 13 1 NM1 QC 1 TEST13 ZACKREY R HN CH01288946 NM1 IL 1 TEST13 JEFFREY A MI 987654321 REF EA 840338645 DTM 050 20131129 AMT AU 890 56 SVC NU 0250 1 5 0 1 DTM 472 20131119 CAS CO B13 1 5 SVC HC254640 RT 3584 890 56 0360 1 DTM 472 20131119 CAS CO 45 2693 44 AMT B6 890 56 LQ HE MA109 SVC HC gt 00834 1796 0 0370 4 DT
6. Companion Guide APPENDIX C TRADING PARTNER ENROLLMENT 26 APPENDIX D CLEARINGHOUSE TRADING PARTNER AGREEMENT 27 APPENDIX E REVISION HISTORY 4 4 420 222 2 28 Table 6 Document Revision HIStory osiensa ie e E E AA E EEES ES 28 Page 5 of 28 PGBA 835 Companion Guide 1 INTRODUCTION Scope Providers billing services and clearinghouses are advised to use the ASC X12N 005010X221A1 Health Care Claim Payment Advice 835 Implementation Guide as a basis for their receipt of Electronic Remittance Advice This companion document should be used to clarify the business rules for 835 data content requirements batch file acknowledgment connectivity response time and system availability specifically for submissions through the system Overview The purpose of this document is to introduce and provide information about PGBA s CAQH solution for receiving batch 835 transactions References CORE Phase III www cagh org benefits php 5 X12 TR3s WWW WpC edi com Trading Partner ERA enrollment www myTRICARE com EDIG Technical User s Manual www myTRICARE com Additional Information e Submitters must have Internet HTTPS connection capability to receive 835 responses e The submitter must be associated with at least one provider in the PGBA provider database e Only batch 8
7. PGBA 835 Companion Guide 10 TRANSACTION SPECIFIC INFORMATION All references to TR3 in this section assume the ASC X12 TR3 835 version referenced in section 1 of this Companion Guide 835 Payment Advice Transaction This section describes the values required by PGBA in the 835 Payment Advice transaction Any segments or elements not referenced in Tables 15 or 16 should be sent on the 835 per Information Source Level Structures Table 5 Header X12 Loop ID Reference unpre AL Codes Notes Comments ame Remittance Transaction Information Only ID Header BPRO1 Handling Code namber H Must be an l or H Notification Only Total Actual BPRO3 Provider payment C Credit Must be C Amount BPRO04 Payment Method Code ACH Automated Clearing House used for electronic funds transfer CHK Check payment made via check NON Non payment Data Must be ACH CHK or NON BPRO5 Payment Format Code CCP Cash Concentration Disbursement plus Addenda CCD ACH Required and used only when 04 equals ACH Page 13 of 28 PGBA 835 Companion Guide X12 Loop ID Reference mper on Codes Notes Comments ame Note Only provided if electronic funds transfer 01 ABA Transit Institution DFI ID Routing Number Required if BPRO4 BPRO6 Number Qualifier including check equals ACH digits 9 digits Identifies the t
8. Payer Business Must equal business contact area PERO2 Contact Name TRICARE Claims that would apply to this Name Administration remittance and all the claims 1000A Business Contact Must equal Code identifying the type Number of business Communication TE Telephone communication number Number Qualifier Number 1000A Complete communications Payer Business number including PEROA Contact country or areacode Differs depending on Communication when applicable contract region Number 1000A Payer Technical Contact Must equal We Code identifier for the 1 Technical Contact Function technical contact Code Department 1000A Must equal Payer Technical TRICARE PERO2 Contact ELECTRONIC enna contact Dames Contact Name CLAIMS SERVICE CENTER 1000A Payer Technical Contact Technical communication FEROS Communication ae ee number qualifier Number Qualifier P 1000A Technical contact number Must equal 1 800 PERO4 ue 325 5920 Communication Number Page 15 of 28 PGBA 835 Companion Guide X12 Loop ID Reference Codes Notes Comments 1000B Must equal FI Federal Taxpayers Identification Number XX National Required when N104 N103 Identification Code Provider Identifier does not contain the Qualifier Note For individual providers as payees use this number to represent the Social Security Number National Provider Identifier
9. adopted for use under HIPAA The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides PGBA 835 Companion Guide Disclosure StAtEMENL cccccccccscssssssecececccecsessssssecececeeeeseessseeececececeesesssseceseccesenesaseseeeccesesenesasaeeeseeseseseneaaes 2 Preface NI NE 3 1 2 2 2 0 20202 77 6 kien x 6 6 ReteretiCes eed tds es epe Pea SEE o esae e dee aa Puce d 6 Additional Informoaltlof c n 6 2 tpe ta waa 6 Working With POGBA 6 Trading Partner 7 3 222205200220 7 Table 1 Testing Process EE E E E E E 7 Transition from Test to Production Status ccccccccccccsssessssececececeesesesseaeeesececsesessnseeeseceeseeeseeseceeeesesenersaaes 7 Testing URLS for Batch through the HTTPS 2 8 4 CONNECTIVITY WITH TH
10. systems involved can properly submit and receive X12 TR3 compliant transactions Step 4 Production Phase Once testing is complete a Trading Partner can begin receiving 835 transactions for providers that have provided an ERA enrollment Detailed information regarding Communication protocol specifications Batch File Responses Administrative Procedures including Schedule Availability Downtime Page 8 of 28 PGBA 835 Companion Guide Notification and Re Transmission Procedures can be found in the EDIG User Manual which is available on the EDI page at www myTRICARE com Security All Trading Partners must assume full responsibility for the privacy and security of all beneficiary data PGBA holds Clearinghouse Submitters responsible for the privacy and security of remittance transactions sent directly to them from Providers and requires them to be able to associate each inquiry with a Provider Provider authentication must be established by the Clearinghouse outside of the transaction 5 CONTACT INFORMATION EDI Customer Service For general inquiries contact the EDI Customer service Help Desk at 1 800 325 5920 option 2 or EDI TRICARE PGBA com EDI Technical Assistance All inquiries and comments regarding Trading Partner registration connectivity set up transaction testing and 835 transaction receipts should be directed to EDIG Operations EDIG Operations is available at 800 868 2505 EDIG OPS PalmettoGBA com Monday th
11. 00 13 1 NM1 QC 1 TEST BENNETT R HN CH01258758 NM1 IL 1 TEST JASON R MI 111111111 REF EA 970320540 DTM 050 20131028 AMT AU 1127 2 1 27 SVC HC gt 99285 1409 1 127 2 0450 1 DTM 472 20131019 CAS CO 45 281 8 AMT B6 1127 2 Page 22 of 28 PGBA 835 Companion Guide LX 2 CLP CH01272757 1 204 63 73 CH 3315X3KJZ 00 13 1 NM1 QC 1 TEST2 BROOKLYN R HN CH01272757 NM1 IL 1 TEST2 ERIC C MI 222222222 REF EA 970113481 DTM 050 20131111 AMT AU 63 73 SVC HC gt 92507 gt GN 204 63 73 0440 1 DTM 472 20131010 CAS CO 45 140 27 AMT B6 63 73 LX 3 CLP CH01277876 1 250 30 97 CH 3315X3KKJ 00 13 1 NM1 QC 1 TEST3 MADISON P HN CH01277876 NM1 IL 1 TESTS JAMES P MI 333333333 REF EA 980672250 DTM 050 20131111 AMT AU 30 97 SVC NU 0250 24 19 2 1 DTM 472 20131107 CAS CO 45 4 8 AMT B6 19 2 SVC HC gt 83036 151 11 77 0301 1 DTM 472 20131107 CAS CO 45 139 23 AMT B6 11 77 SVC HC gt G0108 75 0 0942 1 DTM 472 20131107 CAS CO 96 75 LX 4 CLP CH01278815 1 304 75 16 53 CH 3316X3DBG 00 13 1 NM1 QC 1 TEST4 KEVIN M HN CH01278815 NM1 IL 1 TEST4 FRANCIS P MI 444444444 REF EA 980712618 DTM 050 20131112 AMT AU 16 53 SVC HC gt 36415 22 75 0 0301 1 DTM 472 20131106 CAS CO 97 22 75 SVC HC282947 56 4 76 0301 1 DTM 472 20131106 CAS CO 45 51 24 AMT B6 4 76 SVC HC gt 83036 151 11 77 0301 1 DTM 472 20131106 CAS CO 45 139 23 AMT B6 11 77 SVC HC g
12. 35 outbound files are supported e This system supports PGBA members only 2 GETTING STARTED Working with PGBA Providers billing services and clearinghouses interested in receiving 835 electronic remits via PGBA should refer to section 5 of this Companion Guide for contact information The provider must be TRICARE authorized and the receiver of the 835 remit must have a submitter ID before filling out an ERA enrollment form See Trading Partner Registration Please note that the information in this guide is subject to change Any changes will be available at www myTRICARE com The use of this document is solely for the purpose of clarification The information describes specific requirements to be used in processing PGBA LLC ASC X12 005010X221A1 Health Care Claim Payment Advice Page 6 of 28 PGBA 835 Companion Guide Trading Partner Registration Trading partners must enroll with the PGBA EDI Gateway EDIG Prospective trading partners must complete and submit an EDIG Trading Partner Enrollment Form and the Trading Partner Agreement Documents can be found on the EDI page at www myTRICARE com Please refer to section 5 of this Companion Guide for contact information 3 TESTING WITH PGBA Trading Partners must complete basic transaction submission testing with PGBA Tests must be performed for each X12 transaction type EDIG is available to assist with new Trading Partner testing Monday Friday from 9 00 AM to 5 00 PM ES
13. 9 PGBA A CELERIAN GROUP COMPANY TRICARE HIPAA Transaction Standard Companion Guide ASC X12N 835 005010 221 1 Health Care Claim Payment Advice Version 1 0 January 2014 PGBA 835 Companion Guide Disclosure Statement Please note that the information in this guide is subject to change Any changes will be available at www myTRICARE com This transaction set can be used to post payments to practice management systems for Health care claim payments advice for electronic remits The use of this document is solely for the purpose of clarification The information describes specific requirements to be used in generating an outbound PGBA LLC 5 12 005010X221A1 Health Care Claim Payment Advice 835 transaction The 835 electronic remit returned by PGBA is subject to all Health Plan terms limits conditions exclusions and the member s eligibility at the time services are rendered Page 2 of 28 PGBA 835 Companion Guide Preface Page 3 of 28 This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with PGBA LLC Transmissions based on this companion guide used in tandem with the v5010 ASC X12N Implementation Guides are compliant with both ASC X12 syntax and those guides This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides
14. 99 and TA1 guidelines outlined in the Implementation Acknowledgement for Health Care Insurance Trading Partners must follow the character set guidelines as defined in Section B 1 1 2 2 of the TR3 PGBA uses the delimiters in Table 4 Table 4 835 Delimiters Character Name Delimiter Asterisk Data Element Separator Component Element gt Greater Than Separator Tilde Segment Terminator A Carat Repetition Separator Page 11 of 28 PGBA 835 Companion Guide 8 ACKNOWLEDGEMENTS AND ERROR CODES The receiver of the 835 remit from PGBA is not required to return a 999 acknowledgement CMS 0028 IFC excludes requirements pertaining to acknowledgements CMS 0028 IFC does not adopt batch acknowledgements required in section 4 2 of CAGH CORE rule 350 as the secretary has not yet adopted HIPAA standards for acknowledgements 9 TRADING PARTNER AGREEMENTS Trading Partner enrollment is required to receive 835 remits Refer to the GETTING STARTED section of this Companion Guide under Trading Partner Registration for information regarding enrollment as a Trading Partner The trading partner must be set up as a receiver of the transaction on the Trading Partner table for electronic remits Trading Partners may not receive transactions to be executed as Usage Indicator ISA15 P until testing has been accomplished and approval to receive production transactions has been given Page 12 of 28
15. E 8 Trading Partner Registration Process FIOW cccccccccsssssessecececeeeeeeseseeaececeeeenseeseaececeeeeseneeeeseeeeeeseneensenaaes 8 Figure 1 Process Tor Receiving 835 Transactions 8 Detailed information regarding Communication protocol specifications Batch File Responses Administrative Procedures including Schedule Availability Downtime Notification and Re Transmission Procedures can be found in the EDIG User Manual which is available on the EDI page at www myTRICARE COM 8 TELAM 9 5 CONTACT INFORMATION 0 00508025 9 EDI Customer S6rviC8 tec ete teet eee e 9 EDI Technical Assistance 022200 2 01000 senate sess esas Esnas 9 6 CONTROL 5 1 42 42 1 4 2424 00 9 Interchange Control Structure ISA IEA 9 Table 2 835 ISA Segment 9 Functional Group Structure GS GE rete 10 Table 3 835 GS Segment 10 Transa
16. Guide APPENDIX IMPLEMENTATION CHECKLIST PGBA suggests entities use this information as a checklist of steps to become a submitter e Read and review the EDI Gateway Technical Communications User s Manual e Contact PGBA Technology Support Center at 803 736 5980 or 800 868 2505 with questions Get user ID and password e Send at least one test transaction These tests must be performed for each different transaction type that a trading partner is approved to submit to EDIG e Begin receiving transactions PPENDIX SAMPLE 835 This example includes the minimum required data elements for a PGBA outbound 835 remit file IEA 1 248100097 ISA 00 00 30 571132733 ZZ 7GWnnnnAAn 131203 2043 00501 248100097 0 P gt GS HP 571132733 7GWnnnnAAn 201 31203 204314 7384627 X 005010X221A1 ST 835 000002291 BPR I 4303 69 C ACH CCP 01 043301627 DA 1028900224 1571132733 000000000 01 043000261 DA 1185027 2013120 3 TRN 1 5282937336NR4 1571132733 000000000 REF EV 7GWnnnnAAn REF F2 123456789 R81031202008630 DTM 405 20131202 N1 PR PGBA LLC N3 TRICARE NORTH REGION CLAIMS P O BOX 870140 N4 SURFSIDE BEACH SC 295879740 PER CX TRICARE NORTH REGION CLAIMS CORRESPONDENCE TE 8778742273 PER BL TRICARE ELECTRONIC CLAIMS SERVICE CENTER TE 8003255920 N1 PE CHILDREN S HOSPITAL OF PITTSBU XX 1111111115 N3 PO BOX 382007 N4 PITTSBURGH PA 15250 REF TJ 123456789 LX 1 CLP CHO01258758 1 1409 1127 2 CH 3301X1KC1
17. Interest PGBA LLC valid codes Specifies the type of 2100 QTY01 211 Must use quantity and is provided OU Outlier Days in certain situations Page 18 of 28 PGBA 835 Companion Guide X12 Loop ID Reference Tp Codes Notes Comments Use the adjudicated Composite Medical Procedure Medical Code Identifies ero ds Procedure medical procedure by its Identifier standardized code and modifiers Must equal HC HCPCS Codes Professional Broder of HP Health Insurance Identifies the type source Service ID Prospective Payment of the descriptive number 2110 SVCO1 1 Qualifier System HIPPS Skilled used in Product Service p Nursing Facility Rate ID and is provided if roduct Service ID Qualifier Code available N4 National Drug Code 5 4 2 NU NUBC UB92 Codes Must equal HC HCPCS Codes Professional Product or Sane Rm Qualifies the values in Service ID System HIPPS Skilled SVCO6 2 through 2110 SVC06 1 Qualifier SVCO6 6 It is provided Product Service EISE Seen if available ID Qualifier o NM 4 National Drug Code 5 4 2 NU NUBC UB92 Codes Service Provided when related Identification service specific 2110 REFO1 Reference 2 22 reference identifiers were Identification y used in the process of Qualifier adjudicating this service Must equal Line Item Control Number 5 Qualifies the Reference 2110 REFO1 Reference Identification and is Identification
18. M 472 20131119 CAS CO B13 1796 SVC HC gt J0690 36 25 0 0636 2 DTM 472 20131119 CAS CO B13 36 25 SVC HC 2J3010 13 5 0 0636 1 DTM 472 20131119 CAS CO B13 13 5 SVC HC J7120 106 0 0636 1 DTM 472 20131119 CAS CO B13 106 SVC NU gt 0710 3535 0 3 DTM 472 20131119 CAS CO B13 3535 PLB 250402510 20131231 L6 27 SE 265 000002291 GE 1 7384627 APPENDIX C TRADING PARTNER ENROLLMENT Enrollment with the EDI Gateway requires prospective trading partners to complete and submit the PGBA EDIG Trading Partner Enrollment Form and the Trading Partner Agreement The Page 26 of 28 PGBA 835 Companion Guide purpose of the PGBA EDIG Trading Partner Enrollment Form is to enroll providers software vendors clearinghouses and billing services as trading partners and recipients of electronic data It is important you follow these instructions and complete all the required information We will return incomplete forms to the applicant which could delay the enrollment process The enrollment form is in the Appendix of the EDI Gateway Technical Communications User s Manual and is also available at the HIPAA Critical Center You should complete enrollment forms electronically and email them to EDIG OPS PalmettoGBA com Use your TAB key to move forward through the form fields or click your cursor in a desired field or box Be sure to save the file after you have completed the form The Trading Partner Agreement is a legal do
19. T Table 1 Testing Process Testing Steps Test Instructions Test Plan EDIG and the trading partner agree to a predefined set of test data with expected results In addition a plan must be developed for a test to production transition that considers volume testing and transaction acceptance ratios Connectivity EDIG supported connectivity protocols are listed in section 4 of this Companion Guide Security EDIG will validate approved trading partners are submitting transactions allowed per PGBA enrollment applications Data Integrity Data integrity is determined by EDIG s TR3 editor Testing cannot progress until a trading partner s data receives no TR3 edit errors EDIG expects there may be an occasional situation in which a trading partner s TR3 edit interpretation differs from PGBA s interpretation EDIG will work with the trading partner to resolve such differences on an individual basis Acknowledgment Trading partners must demonstrate the ability to receive Response acknowledgment and response transactions Transactions Results Analysis EDIG and the trading partner will review acknowledgment and response transactions for consistency with the predefined expected results Transition from Test to Production Status When test results have satisfied the test plan and the Trading Partner Agreement has been executed the trading partner s submission status is changed from test to production At t
20. ction set control numbers ST SE ccccccccccccscsssssscececceeceesesssececececsesessseseeeeeeseseeeseeaeeeseceeseneneaaes 11 T PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS 11 General Structural 11 Table 4 835 Delifillels a ruere heus GI ep IE 11 8 ACKNOWLEDGEMENTS AND ERROR 5 12 The receiver of the 835 remit from PGBA is not required to return a 999 acknowledgement per CMS 0028 IFC excludes requirements pertaining to 12 9 TRADING PARTNER 12 10 TRANSACTION SPECIFIC 13 835 Payment Advice TrarisactiOnc i e eite erem eb etel 13 Information Source Level 13 Table 5 Headet correr e e Feci ae eee C Eo a Re CHE 13 17 Table S Ty ETT 21 APPENDIX A IMPLEMENTATION CHECKLIST 22 PPENDIX SAMPLE 835 Haie tonta eu 22 Page 4 of 28 PGBA 835
21. cument All trading partners are required to print complete and return the originally signed hard copy via mail prior to being moved to production status The PGBA Trading Partner Agreements can be found at the HIPAA Critical Center The PGBA Trading Partner Agreement can be found on myTRICARE com in the Electronic Claims Filing section If you are a prospective PGBA LLC trading partner print and mail a hard copy of the completed Trading Partner Agreement to Palmetto GBA Attention EDIG Operations AG 280 2300 Springdale Drive Building One Camden SC 29020 1728 APPENDIX D CLEARINGHOUSE TRADING PARTNER AGREEMENT The agreement can be downloaded from www myTRICARE com Electronic Filing Page Page 27 of 28 PGBA 835 Companion Guide APPENDIX E REVISION HISTORY Table 6 provides a summary of changes made to this document Table 6 Document Revision History Version Date Description of Changes 1 0 01 01 2014 Initial version Page 28 of 28
22. his time the trading partner can begin to receive production transaction data Page 7 of 28 PGBA 835 Companion Guide Testing URLs for Batch through the HTTPS channel Information regarding the HTTPS channel can be found in the Web Service Integration Requirements for External Partners on the EDI page at www myTRICARE com SOAP https services pgba com QA 9080 COREElectronicDatalnterchange MIME https services pgba com QA mimeapi 9080 COREElectronicDatalnterchange 4 CONNECTIVITY WITH THE PAYER COMMUNICATIONS Trading Partner Registration Process Flow To access the 835 application potential Trading Partners need to register and obtain a trading partner ID from EDIG Figure 1 illustrates the high level process for successfully registering as a Trading Partner and receiving 835 transactions Figure 1 Process for Receiving 835 Transactions Step 1 Step 2 Step 3 Step 4 Trading P artner Trading P artner Testing Status Production Status Registration Authentication Step 1 Trading Partner Registration Complete and submit the Trading Partner Enrollment Form and the Trading Partner Agreement See the GETTING STARTED section of this Companion Guide Step 2 Trading Partner Authentication EDIG will verify the information on the Trading Partner Agreement Form and approve or deny any Submitter ID requests Step 3 Testing Phase EDIG will coordinate with a Trading Partner to send test transactions and verify that all
23. rough Friday from 8 00 AM to 5 00 PM EST NOTE The EDIG Operations E mail account is monitored during normal business hours E mails are typically answered within 3 business days 6 CONTROL SEGMENTS ENVELOPES The following sections describe the 835 transaction requirements to be used in conjunction with the requirements outlined in the ASC X12 TRS Adhering to these requirements will help ensure that transactions received by the 835 application will pass the specified business edits All references to the ASC X12 835 TR3 assume the version referenced in section 1 of this Companion Guide Interchange Control Structure ISA IEA Table 2 describes the values to be populated in the ISA segment of the outbound 835 transaction The IEA segment should be populated as instructed by the ASC X12 TR3 Table 2 835 ISA Segment Rules Page 9 of 28 PGBA 835 Companion Guide Segment Id Data Element Description 5 01 Authorization Info 00 Qualifier ISA02 Authorization Information Blanks ISA03 Security Information 00 Qualifier ISA04 Security Information Blanks ISA05 Interchange ID Qualifier 30 ISA06 Interchange Sender ID 571132733 ISA07 Interchange ID Qualifier ZZ ISA08 Interchange Receiver ID EDIG assigned Trading Partner ID ISA09 Interchange Date Populated by EDIG ISA10 Interchange Time Populated by EDIG ISA11 Repetition Separator Populated by EDIG ISA12 Interchange Con
24. t G0108 75 0 0942 1 DTM 472 20131106 CAS CO 96 75 LX 5 CLP CHO01281707 1 840 75 16 25 47 85 CH 3319X30TR 00 13 1 NM1 QC 1 TEST5 YANNI Y HN CHO1 281 707 NM1 IL 1 TEST5 GEORGE Y MI 555555555 REF EA 840359897 DTM 050 20131115 AMT AU 64 1 SVC HC gt 36415 22 75 0 0301 1 DTM 472 20131106 CAS CO 97 22 75 SVC HC gt 80061 167 16 25 0301 1 DTM 472 20131106 Page 23 of 28 PGBA 835 Companion Guide CAS CO 45 150 75 AMT B6 16 25 SVC HC gt 82947 56 0 0301 1 DTM 472 20131106 CAS CO 45 51 24 CAS PR 1 4 76 AMT B6 4 76 SVC HC gt 83036 151 0 0301 1 DTM 472 20131106 CAS CO 45 139 23 CAS PR 1 11 77 AMT B6 11 77 SVC HC284439 133 0 0301 1 DTM 472 20131106 CAS CO 45 122 06 CAS PR 1 10 94 AMT B6 10 94 SVC HC gt 84443 161 0 0301 1 DTM 472 20131106 CAS CO 45 140 62 CAS PR 1 20 38 AMT B6 20 38 SVC HC gt G0108 150 0 0942 2 DTM 472 20131106 CAS CO 96 150 LX 6 CLP CHO01292409 1 226 9 42 2 35 CH 3331X36Q7 00 13 1 NM1 QC 1 TEST6 JOSEPH P HN CH01292409 NM1 IL 1 TEST6 MICHAEL N MI 666666666 REF EA 981108767 DTM 050 20131127 AMT AU 11 77 SVC HC gt 83036 151 9 42 0301 1 DTM 472 20131119 CAS CO 45 139 23 CAS PR 2 2 35 AMT B6 11 77 SVC HC gt G0108 75 0 0942 1 DTM 472 20131119 CAS CO 96 75 LX 7 CLP CH01293308 1 1349 25 768 56 CH 3333X1 16D 00 13 1 NM1 QC 1 TEST7 KASSIDY P HN CH01293308 NM1 IL 1 TEST7 BRIAN MI 777777777 REF EA 980811182
25. trol 00501 Version Number ISA13 Interchange Control Assigned by EDIG Number ISA14 Acknowledgment 1 Requested ISA15 Usage Indicator P T production or test indicator ISA16 Component Element Populated by EDIG Separator Functional Group Structure GS GE Table 3 describes the values populated in the GS segment of the 835 transaction The GE segment is populated as instructed by the ASC X12 270 TR3 Table 3 835 GS Segment Rules Segment Data Element Description GS01 Functional Identifier Populated by EDIG GS02 Application Sender s Code 571132733 GS03 Application Receiver s Codd EDIG assigned Trading Partner ID GS04 Date Populated by EDIG Page 10 of 28 PGBA 835 Companion Guide seamen Data Element Description GS05 Time Populated by EDIG GS06 Group Control Number Assigned by EDIG 9507 Responsible Agency Code Version Release Industry GS08 Identifier Populated by EDIG Transaction set control numbers ST SE Trading Partners should follow the ST SE guidelines outlined in the 835 TR3 7 PAYER SPECIFIC BUSINESS RULES AND LIMITATIONS This section describes the business rules and limitations of the 835 application All references to the ASC X12 835 TR3 assume the version referenced in section 1 of this Companion Guide General Structural Notes Trading Partners should follow the ISA IEA and GS GE guidelines for HIPAA in Appendix C of the TR3 and follow the 9
26. ype of identification number of Depository Must use Depository Financial Financial 01 ABA Transit Institution DFI Required BPR12 Institution DFI Routing Number when BPR04 equals ACH Identification including check BOP or FWT Not used if Number Qualifier digits 9 digits BPRO04 equals Check Payment Effective Required when BPR04 BPR16 Date EFT effective date ACH Reassociation Reference EFT reference Required when BPR04 TRAO Identification number ACH Number n Must equal Required payer 571182708 Identification number Must use Receiver Clearing house or Identifies the transaction REBO Identification billing service trading receiver partner Mailbox ID Will be a 9 digit tax ID This is the TRICARE F2 REFO02 eo Provider with or without 3 digit provider number used to location suffix adjudicate the claim Required if the National Payer Name Must equal PGBA Plan ID is not transmitted 10905 LLC in N104 Payer Identifier Must equal first address Ped Address TRICARE Claims line by region 1000A N301 Information Page 14 of 28 PGBA 835 Companion Guide X12 Loop ID Reference a sear eral Codes Notes Comments Reference Msi ues Code used to qualify the REFO1 Identification 2U Payer additional payer Qualifier identification Number identification numbers 1000A Required when there is a
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