ANSI 837 - Florida Blue - BCBSF

Florida Blue 837P Companion Guide 2012Florida BlueHIPAA Transaction Standard Companion GuideFor Availity® Health Information Network UsersRefers to the Technical Reports Type 3 Based on ASC X12 version005010X222A1837 P – Health Care Claim ProfessionalCompanion Guide Version Number: 4.2December 20121900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012DisclaimerThe Florida Blue Companion Guide for EDI Transactions Technical Reports, Type 3 (TR3) providesguidelines in submitting electronic batch transactions. Because the HIPAA ASC X12- TR3s requiretransmitters and receivers to make certain determinations /elections (e.g., whether, or to whatextent, situational data elements apply), this Companion Guide documents those determinations,elections, assumptions or data issues that are permitted to be specific to Florida Blue businessprocesses when implementing the HIPAA ASC X12 5010 TR3s.This Companion Guide does not replace or cover all segments specified in the HIPAA ASC X12 TR3s.It does not attempt to amend any of the requirements of the TR3s, or impose any additionalobligations on trading partners of Florida Blue that are not permitted to be imposed by the HIPAAStandards for Electronic Transactions. This Companion Guide provides information on Florida Bluespecific codes relevant to Florida Blue business processes and rules and situations that are withinthe parameters of HIPAA. Readers of this Companion Guide should be acquainted with the HIPAAASC X12 TR3s, their structure, and content.This Companion Guide provides supplemental information that exists between Florida Blue and itstrading partners. Trading partners should refer to their Trading Partner Agreement for guidelinespertaining to Availity® 1 LLC, legal conditions surrounding the implementation of the electronic datainterchange (EDI) transactions and code sets. However, trading partners should refer to thisCompanion Guide for Information on Florida Blue business rules or technical requirementsregarding the implementation of HIPAA-compliant EDI transactions and code sets.Nothing contained in this Companion Guide is intended to amend, revoke, contradict or otherwisealter the terms and conditions of your applicable Trading Partner Agreement. If there is aninconsistency between the terms of this Companion Guide and the terms of your applicable TradingPartner Agreement, the terms of the Trading Partner Agreement will govern. If there is aninconsistency between the terms of this Companion Guide and any terms of the TR3, the relevantTR3 will govern with respect to HIPAA edits, and this Companion Guide will control with respect tobusiness edits.21 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Table of ContentsDisclaimer 2I. INTRODUCTION 5What is HIPAA 5010? 5What is NPI? 5What is a Taxonomy Code? 5Purpose of the Technical Reports Type 3 Guides 6How to obtain copies of the Technical Report Type 3 Guides 6Purpose of this 837P Companion Guide 6About Availity L.L.C. – Patients. Not Paperwork. 7Registration with Availity 7II. ASC X12 TRANSACTIONS SUPPORTED 7III. GENERAL INFORMATION 8EDI Technical Assistance 8Password Changes 8IV. EDI PROCESSING AND ACKNOWLEDGEMENTS 8EDI Processing Hours 8TA1 Interchange Acknowledgements Transaction 8999 Functional Acknowledgements Transaction 831 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012V. PAYER – Definitions 9VI. 837P CONTROL SEGMENTS, ENVELOPES AND BUSINESS REQUIREMENTS 10Global Information 10Enveloping Information 12Business Requirements 14VII. BILLING REQUIREMENTS FOR ANCILLARY PROVIDERS 20Required Billing Information 20Appropriately Billing Provider Identifiers 20Specialty Pharmacy 21VIII. NPI Matrices 23NPI Attributes 23NPI TR3 Location Information 23IX.HELPFUL TIPS FOR AVOIDING PROVIDER IDENTIFIER ERRORS ONELECTRONIC CLAIMS24X. TIPS FOR SENDING COB INFORMATION ON ELECTRONIC CLAIMS 28XI. COMMUNICATION / CONNECTIVITY PROTOCOLS SUPPORTED 30XII. TRADING PARTNER AGREEMENT 3141 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012837 Health Care Professional Claim Companion Guide (5010)I. IntroductionWhat is HIPAA 5010?The Health Insurance Portability and Accountability Act (HIPAA) requires the health care industry inthe United States to comply with the electronic data interchange (EDI) standards as established bythe Secretary of Health and Human Services. The ASC X12 005010X222A1 is the establishedstandard for Health Care Professional Claims (837P).What is NPI?The National Provider Identifier (NPI) is required wherever you identify a provider or providerorganization in any standard covered HIPAA-AS electronic transaction. The NPI must be valid and itmust be registered with Florida Blue.If you are a provider or provider organization who needs to obtain an NPI, please accessthe National Plan and Provider Enumeration System (NPPES)at https://nppes.cms.hhs.gov/NPPES/Welcome.do . To register your NPI with Florida Blue, pleaseaccess our NPI Notification Format http://www.bcbsfl.com/DocumentLibrary/Providers/Content/NPI_ProviderNotificationForm.pdf.What is a Taxonomy code, and is it required for Florida Blue?Taxonomy codes are administrative codes that identify the provider type and area of specializationfor health care providers. Each taxonomy code is a unique ten character alpha-numeric code thatenables providers to identify their specialty. Taxonomy codes are assigned at both the individualand organizational provider levels.Taxonomy codes have three distinct levels: Level I is provider type, Level II is classification, andLevel III is the area of specialization. A complete list of taxonomy codes can be found onthe National Uniform Claim Committee website at https://www.nucc.org.Taxonomy codes are required by Florida Blue under specific circumstances. Taxonomy is one ofseveral data elements used by Florida Blue to help determine the appropriate provider record forprocessing. In cases where the NPI is shared by multiple provider entities, specialties or locations,the taxonomy becomes a critical data element.51 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012For example:ABC Hospital, Urgent Care, Lab and Physician PA Group all share the same NPI. Inthis case, the taxonomy becomes critical to ensure appropriate processing and feeschedule assignment.Purpose of the Technical Reports Type 3 GuidesThe Technical Report Type 3 Guide (TR3) for the 837 Health Care Professional Claim transactionspecifies in detail the required formats. It contains requirements for the use of specific segmentsand specific data elements within segments, and was written for all health care providers and othersubmitters. It is critical that your software vendor or IT staff review this document carefully andfollow its requirements to send HIPAA-compliant files to Florida Blue via your vendor.How to Obtain Copies of the Technical Reports Type 3 GuidesTR3 Guides for ASC X12 005010X222A1 Health Care Professional Claim (837 P) and all other HIPAAstandard transactions are available electronically at the Washington Publishing website (www.wpcedi.com).Purpose of this 837 Companion GuideThis 837 Companion Guide was created for Florida Blue trading partners to supplement the 837TR3. It describes the data content, business rules, and characteristics of the 837 transaction.61 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012About Availity L.L.C. – Patients. Not Paperwork. ®Availity optimizes information exchange between multiple health care stakeholders through asingle, secure network. The Availity ® Health Information Network encompasses administrative,financial, and clinical services, supporting both real-time and batch EDI via the web and throughbusiness to business (B2B) integration. For more information, including an online demonstration,please visit www.availity.com or call 1 (800)-AVAILITY (282-4548).Registration with Availity:In order to register, you’ll need:1. Basic information about your practice, including your Federal Tax ID and National ProviderIdentifier.2. Someone with the legal authority (typically an owner or senior partner) to sign agreements foryour organization.3. An office manager or other employee who can oversee the Availity implementation andmaintain user IDs and access.II.ASC X12 Transactions SupportedIMPORTANT NOTE: If you submit your transactions through Availity, please refer to the Availity EDIGuide located on the Availity website at www.Availity.com.Florida Blue processes the following ASCX12 transactions for Professional Claim SubmissionsASC X12 837 005010X222A1Professional Claim SubmissionASC X12 TA1 v005010X231A1ASC X12 999 v005010X231A1Response to the X12 transactions where errorsare encountered in the outer envelopes(ISA/IEA and GS/GE segments)Functional Acknowledgement - Response to theX12 transactions where structural and syntacticalerrors are encountered within the transactionsegments itself (ST-SE segments)71 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012III.General InformationEDI Technical Assistance for Availity Users:Your first point of contact is the Availity Customer Support Team. If necessary, this team will triageyour issue to Florida Blue. Availity Customer Support can be reached at 1-800-AVAILITY (282-4548).IV.EDI Processing and AcknowledgementsIMPORTANT NOTE: If you submit your transactions through Availity, please refer to the Availity EDIGuide located on the Availity website at www.availity.com for processing and acknowledgementsinformation. The purpose of this section is to outline Florida Blue processes for handling the initialprocessing of incoming files and the electronic acknowledgment generation process.EDI Processing HoursThe 837 Health Care Professional Claim transaction files can be transmitted seven days a week, 24hours a day. Standard EDI processing hours are Monday through Friday, 12:01 a.m. to 6:00 p.m.Files received after 6:00 p.m. will be processed the next business day. Files are not processed onweekends or company holidays.TA1 Interchange Acknowledgement TransactionAll X12 file submissions are pre-screened upon receipt to determine if the ISA or IEA segments arereadable. If errors are found, a TA1 response transaction will be sent to notify the trading partnerthat the file could not be processed provided the file contains a code value of 1 in the ISA14 of theinbound transaction. No TA1 response transaction will be sent for error-free files.Once Florida Blue determines that the file is readable, validation is performed on the ISA and IEAloop information. If these segments have a non-standard structure, the file will receive a full filereject and the TA1 response transaction will be sent to the trading partner, provided the filecontains a code value of 1 in the ISA14.999 Functional Acknowledgement TransactionIf the file submission passes the ISA/IEA pre-screening above, it is then checked for ASC X12 syntaxand HIPAA compliance errors. When the compliance check is complete, a 999 Acknowledgementwill be sent to the trading partner informing them if the file has been accepted or rejected. Ifmultiple transaction sets (ST-SE) are sent within a functional group (GS-GE), the entire functionalgroup (GS-GE) will be rejected when an ASC X12 or HIPAA compliance error is found.81 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012V. Payer - DefinitionsIMPORTANT NOTE: If you submit your transactions through Availity, please refer to the Availity EDIguide at www.Availity.com. This section is specifically intended for trading partners who exchangetransactions directly with Florida Blue.The purpose of this section is to delineate specific data requirements where multiple valid valuesare presented within the 5010 TR3.• Interchange control header (ISA06) Interchange Sender ID (Mailbox ID) – is individuallyassigned to each trading partner.• Interchange control header (ISA08) Interchange Receiver ID – is the Florida Blue tax ID,592015694.• Interchange control header (ISA15) Usage Indicator – defines whether the transaction is atest (T) or production (P).• Functional Group Header (GS02) Application Sender’s code – is individually assigned toeach trading partner.91 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012VI.837P Control Segments & EnvelopesReq #G1Loop ID – Segment Description& Element NameAll Transactions for Availity UsersonlyTR3 DataElementGlobal InformationTR3 Page(s)Plan RequirementFlorida Blue requires a Trading Partner Agreementto be on file with Availity indicating all electronictransactions the Trading Partner intends to send orreceiveG2 All Segments Only loops, segments, and data elements valid forthe 837 HIPAA-AS TR3 Guide ASC X12005010X222A1 will be used for processing.G3 Acknowledgements –Florida Blue acknowledgementsare created to communicate thestatus of transactions. It isimperative that they be retrievedon a daily basis. One file couldresult in multipleacknowledgements.ANSI X12:TA1 is available immediately after “depositing file”999 is available immediately after “depositing file”Files and/or claims that do not pass edits areindicated on these acknowledgements and must becorrected and resubmitted.Availity Users: Availity will forward Florida Blueacknowledgements to the submitter. Please referto the Availity EDI Guide at www.Availity.com.- TA1 – InterchangeAcknowledgement- 999 – FunctionalAcknowledgementG4 Negative Values Submission of any negative values in the 837transaction is not allowed.G5 Date fields All dates submitted on an incoming 837 HealthCare Professional Claim must be a valid calendardate in the appropriate format based on therespective TR3 qualifier. Failure to do so maycause processing delays or claims being returned asa provider correctable error. These must be101 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan Requirementcorrected and resubmitted electronically.G6 Batch Transaction Processing Generally, Availity and Florida Blue Gatewaysaccept transmissions 24 hours a day, 7 days aweek.G7 All transactions – B2B / EDI Florida Blue requires that “-“ (dashes) be removedfrom all Tax IDs, SSNs and Zip codes.G8 All transactions Florida Blue requires that no special characters besubmitted in any text fields.111 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Enveloping Information – 837 Professional Claim SubmissionIMPORTANT NOTE: If you submit your transactions through Availity, please refer to the Availity EDIguide at www.Availity.com. This section is specifically intended for trading partners who exchangetransactions directly with Florida Blue.Req #E1Loop ID - Segment Description &Element NameInterchange Control HeaderAuthorization Information QualifierTR3DataElementISA01TR3 Page(s)Appendix C(C.4)Plan RequirementFlorida Blue requires 00 in this field.E2Interchange Control HeaderAuthorization InformationISA02Appendix C(C.4)Florida Blue requires 10 spaces in this field.E3Interchange Control HeaderSecurity Information QualifierISA03Appendix C(C.4)Florida Blue requires 00 in this field.E4Interchange Control HeaderSecurity InformationISA04Appendix C(C.4)Florida Blue requires 10 spaces in this field.E5Interchange Control HeaderInterchange ID QualifierISA05Appendix C(C.4)Florida Blue requires 01 in this field.E6Interchange Control HeaderInterchange Sender IDISA06Appendix C(C.4)Florida Blue requires submission of yourindividually assigned Florida Blue sender mailboxnumber in this field.E7Interchange Control HeaderInterchange ID QualifierISA07Appendix C(C.5)Florida Blue requires ZZ in this field.E8Interchange Control HeaderInterchange Receiver IDISA08Appendix C(C.5)Florida Blue will only accept the submission ofFlorida Blue Tax ID number 592015694 in this field.E9Interchange Control HeaderAcknowledgement RequestedISA14Appendix C(C.6)The TA1 will not be provided without a code valueof 1 in the field.121 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #E10Loop ID - Segment Description &Element NameInterchange Control HeaderFunctional GroupHeader/Functional Group TrailerTR3DataElementGS - GEISA - IEATR3 Page(s)Appendix C(C.7)Plan RequirementFlorida Blue will only process one transaction typeper GS-GE (functional group). However, we willprocess multiple ST’s within one (1) GS-GE groupas long as they are all the same transaction type.E11Functional Group HeaderFunctional Identifier CodeGS01Appendix C(C.7)HC– Health Care Claim - ProfessionalFlorida Blue requires submission of the abovevalue in this field.E12Functional Group HeaderApplication Sender's CodeGS02Appendix C(C.7)Florida Blue requires the submission of the FloridaBlue assigned Sender Code in this field.E13Functional Group HeaderApplication Receiver's CodeGS03Appendix C(C.7)592015694Florida Blue requires the submission of the abovevalue in this field for 837 Professional ClaimSubmission, all others may cause rejection.E14Implementation ConventionReferenceST03 70 Must contain 005010X222A1.131 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Business Requirements for all Florida Blue and AvailityTrading Partners and ProvidersFailure to abide by these requirements will result in provider correctable errors and must becorrected and resubmitted.Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan RequirementB11000A - Submitter PrimaryIdentification NumberNM10975 Florida Blue requires the submission of the FloridaBlue assigned Sender Code in this data element.Identification CodeB21000A – Submitter EDI ContactInformationSubmitter Contact NamePER 0277 Required when the contact name is different thanthe name contained in the Submitter Namesegment of this loop and it is the first iteration ofthe Submitter EDI Contact Information Segment.B31000B – Receiver NameLast Name or Organization NameNM10380 BCBSFFlorida Blue requires submission of above value inthis field.B41000B – Receiver NameReceiver Primary IdentificationNumberNM10980 592015694Florida Blue requires submission of above value inthis fieldB52000B – Subscriber HierarchicalLevelClaim Filing Indicator CodeSBR09 118 BLFlorida Blue requires submission of the above valuein this field.B6 2000A-Billing Provider Taxonomy PRV03 83 Taxonomy codes are required by Florida Blueunder specific circumstances. Taxonomy is one ofseveral data elements used by Florida Blue to helpdetermine the appropriate provider record forprocessing. In cases where the NPI is shared bymultiple provider entities, specialties or locations,the taxonomy becomes a critical data element.Taxonomy codes can be located at www.nucc.org.141 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012For example. ABC hospital, Urgent Care, Lab andPhysician PA group all share the same NPI. In this

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan Requirementcase the taxonomy becomes critical to ensureappropriate processing and fee scheduleassignment.B7B8B92010AA – Billing Provider NPIReference Identification code2010AA – Billing Provider ZipCode2010AB – Pay to Provider ZipCodeNM109 90 Florida Blue requires the Billing providers NPI.Invalid or missing NPI will result in claims beingreturned as a provider correctable error. Thesemust be corrected and resubmitted electronically.N403 92 A valid full 9 digit zip code is required.N403 104 A valid full 9 digit zip code is required.B102010BA - Subscriber NameNM108122Florida Blue requires MI in NM108Identification Code QualifierSubscriber Primary IdentifierNM109123Florida Blue requires submission of the ID numberin NM109 exactly as it appears on the member’s IDcard, including any applicable alpha prefix or suffixDo not use any embedded spaces or the claimcould be returned as a provider correctable errorand must be corrected and resubmitted.B112010BA – Subscriber Address &City/ State/ Zip CodeN3N4124125Florida Blue requires submission of the subscriber’saddress when the subscriber has a FederalEmployee Program (FEP) contract, identified asbeginning with “R” and followed by 8 numericcharacters.B122010BB – Payer NamePayer NameNM103 134 BCBSFFlorida Blue requires submission of above value inthis field.B132010BB – Payer NameNM108134 PI – Payor IdentificationQualifierNM10900590 - Florida Blue Plan Code IDPayer IDFlorida Blue requires submission of above value in151 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan Requirementthis field.B14 2300 - Claim Information /2400 - Service Line NumberMonetary AmountCLM02SV102159354The total claim charge amount must equal the sumof all submitted line items. Failure to do so willresult in claims being returned as a providercorrectable error and must be corrected andelectronically resubmitted.Line Item Charge AmountNote: If the whole dollar amounts are sent inmonetary elements, do not include the decimal ortrailing zero (E.g. $30 = 30).When indicating the dollars & cents, the decimalmust be indicated (E.g. $30.12 = 30.12).B15B16B172300 – Claim InformationClaim Frequency Type Code2300 - Claim InformationHealth Care Diagnosis Code2310B – Rendering Provider NPIRendering Provider Identifier16CLM05-3 159 Florida Blue will accept only the following codes:0 =Non-Payment/Zero1 =Admit Through Discharge Claim7 = Replacement Of Prior Claim8 = Void/Cancel Of Prior ClaimNote: When submitting the corrected claim, theoriginal Reference Number (ICN/DCN) also knownas the Original Claim Number is required to besent in loop 2300 REF. (REF01= F8 qualifier forOriginal Reference Number, REF02 = Original ClaimNumber) .HI 226 Florida Blue requires that you do not transmit thedecimal points in the diagnosis codes. The decimalpoint is assumed.NM109 264 When Rendering Provider is submitted, therendering provider’s NPI is required on all claims.Invalid or missing NPI will result in claims beingreturned as a provider correctable error and mustbe corrected and resubmitted.Exception: When a facility/group provider type bycontract does not require an individual rendering1 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan Requirementphysician reported on the claim, then no renderingprovider information loop should be submitted.For example: Master Clinicians renderingservices at a Behavioral Health OutpatientCenter (BHOC) – only submit the billing providerloop and NO rendering provider loopB182310B – Rendering ProviderTaxonomyPRV03 265 Taxonomy codes are required by Florida Blueunder specific circumstances. Taxonomy is one ofseveral data elements used by Florida Blue to helpdetermine the appropriate provider record forprocessing. Taxonomy codes can be locatedat www.nucc.org.B19 2310C-Service Facility Zip Code N403 273 A valid full 9 digit zip code is required when aservice facility is submitted.B20B212320 - Other SubscriberInformationClaim Filing Indicator Code2320 - Outpatient AdjudicationInformationSBR09 298 In Loop 2320, if SBR09=MB, Florida Blue requires:• More than 30 days have elapsed from theMedicare Remittance date beforesubmitting to Florida Blue (see B24)• the Medicare Report Number must bereported (see B23)• Applicable payment and adjustmentamounts – Medicare’s Allowed and TotalPaid, Patient Deductible, Coinsurance,Copay and Total Liability Amounts.• Claim Adjustment Reason Codes (CARCs)and Remittance Advice Reason Codes(RARCs) that were reported on theMedicare Remittance AdviceMOA 310 Report Remittance Advice Reason Codes that werereported on the previous payer’s RemittanceAdvice. Florida Blue requests that this informationbe provided to facilitate claims processing.B22 2330B - Other Payer Name NM108 321 Florida Blue requires the “PI” qualifier in this field.171 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan RequirementB232330B - Other Payer Claim ControlNumberREF01REF02331 If LOOP ID – 2330B OTHER PAYER NAME issubmitted in the transaction, then the OtherPayer’s Claim Control Number must be reported inthe following REF segment or the claim will bereturned as a provider correctable error and mustbe corrected and resubmitted electronically.B242330B - Other Payer Claim ControlNumberDTP01DTP03• REF01=F8• REF02= Other Payer’s Claim ControlNumber; If the other payer is Medicare,enter the Medicare Report Number (aka –Medicare ICN)325 When SBR09=MB, Florida Blue requires:More than 30 days have elapsed from theMedicare Remittance date before submitting toFlorida BlueB252400 – Service Line NumberSV101-1 352 HC• DTP01=573• DTP02=D8• DTP03=Date Claim Paid (aka MedicareRemittance Date)Product/Service ID QualifierFlorida Blue requires submission of above value inthis field as only HCPCS Procedure codes areaccepted by Florida Blue at this time.B262400 - Professional ServiceProcedure Modifier(s)SV101- 3SV101- 4353 Please submit the appropriate modifiers in priorityorder.SV101-5SV101-6B272410 - Drug IdentificationLIN424DME ProvidersDrug IdentificationDrug QuantityCTP426LIN – NDC must be submittedCTP – Quantity must be submitted.Note:Refer to Specialty Pharmacy Billing Section VII.C.181 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Req #Loop ID – Segment Description& Element NameTR3 DataElementTR3 Page(s)Plan RequirementB282410 - Drug IdentificationNational Drug Code (NDC)LIN03425 NDC Code Format (11-digits using 5-4-2 format[i.e., 5-digits, followed by 4-digits, followed by 2-digits]. Do not include any hyphens or spaces (e.g.,01234567891).B292420A – Rendering Provider NPIRendering Provider IdentifierNM109 430 When Rendering Provider is submitted, therendering provider’s NPI is required on all claims.Invalid or missing NPI will result in claims beingreturned as a provider correctable error and mustbe corrected and resubmitted.Exception: When a facility/group providertype by contract does not require an individualrendering physician reported on the claim,then no rendering provider information loopshould be submitted.For example: Master Clinicians renderingservices at a Behavioral Health OutpatientCenter (BHOC) – only submit the billingprovider loop and NO rendering providerloopB30 2420C – Service Facility Zip Code N403 445 A valid full 9 digit zip code is required when aservice facility is submitted.B312430 - Line AdjudicationInformationDTP01DTP03490 When SBR09=MB, Florida Blue requires:More than 30 days have elapsed from theMedicare Remittance date before submitting toFlorida Blue• DTP01=573• DTP02=D8• DTP03=Date Claim Paid (aka MedicareRemittance Date)191 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012VII.Billing Requirements for Ancillary ProvidersIf ancillary providers have a Blue Cross and Blue Shield of Florida, Inc. (BCBSF) and/or HealthOptions, Inc. provider agreement that does not require the registration of employed healthcare providers, then only the billing provider information should be populated on the claim.If the BCBSF and/or Health Options provider agreement requires registration of employedhealth care providers, then the rendering and billing NPI should be billed appropriately onclaims.Important Note: When billing Referring Physician Information, the Referring Physician’sNPI is always required for Florida Blue.A. The following is a sample of necessary provider billing information required on the837P:• Ancillary Provider with registered employed health care providers• Rendering provider NPI (loop 2310B & 2420A)• Billing provider NPI (loop 2010AA)• Ancillary Provider with no registered employed health care providers:• Rendering provider NPI – Blank• Billing provider NPI (loop 2010AA)B. Appropriately Billing Provider IDsThis information provides the technical details for the 837p Loops for the NPI, Tax ID andTaxonomy Codes.1. Billing Provider:• National Provider ID (NPI) in Loop 2010AA, Segment NM1, Elements NM101 = 85,NM108=XX and NM109=NPI(e.g.,:NM1*85*1*PROVIDERLASTNAME*PROVIDERFIRSTNAME****XX*1234567890~)• Federal Tax ID in Loop 2010AA, Segment REF, Elements REF01=EI and REF02 = Tax ID(e.g., REF*EI*123456789~)• Taxonomy in Loop 2000A, Segment PRV, Elements PRV01 = BI, PRV02 = PXC, PRV03 =Provider Taxonomy2. Referring Provider:201 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012• Claim Level - Referring/Ordering Provider in Loop 2310A, Segment NM1, Elements NM101= DN, NM108 = XX and NM109 = NPI• ( e.g. NM1✽DN✽1✽WELBY✽MARCUS✽W✽✽JR✽XX✽1234567891~• Service Line Referring Provider in Loop 2420F, Segment NM1, Elements NM101 = DN,NM108 = XX, NM109 = NPI(e.g., NM1✽DN✽1✽WELBY✽MARCUS✽W✽✽JR✽XX✽1234567891~)3. Rendering Provider:• Claim Level Rendering Provider in Loop 2310B, Segment NM1, Elements NM101 = 82,NM108 = XX and NM109 = NPI(e.g., NM1✽82✽1✽DOE✽JANE✽C✽✽✽XX✽1234567804~)• Service Line Rendering Provider in Loop 2420A, Segment NM1, Elements NM101 = 82,NM108 = XX and NM109 = NPI(e.g., NM1✽82✽1✽DOE✽JANE✽C✽✽✽XX✽1234567804~)C. Specialty PharmacyTo ensure proper pricing for services, specialty pharmacy providers must include the following onelectronic (837-P 2410 Loop – Drug Identification) claims submitted to BCBSF:1. Ordering Provider:• Service Line Ordering Provider in Loop 2420E, Segment NM1, Elements NM101 = DN,NM108 = XX, NM109 = NPI(e.g., NM1✽DK✽1✽RICHARDSON✽TRENT✽✽✽✽XX✽1234567891~)2. HCPCS Information211 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1• This information provides the technical details for the 837p Loops for the HCPCS code andHCPCS units.• HCPCS code in Loop 2400, Segment SV1, Element SV101= HCPCS Code• HCPCS units in Loop 2400, Segment SV1, Element SV104= HCPCS UnitsFlorida Blue December 2012

Florida Blue 837 P Companion Guide 20123. NDC Qualifier and NDC Code• This information provides the technical details for the 837p Loops for the NDC Qualifier andNDC Code.• Bill the NDC qualifier (“N4”) and NDC Code (11-digits using 5-4-2 format [i.e., 5-digits, followed by 4-digits, followed by 2-digits]). Do not include any hyphens orspaces (e.g., 01234567891).• NDC Qualifier in Loop 2410, Segment LIN, Element LIN02 = N4• NDC Code in Loop 2410, Segment LIN, Element LIN03 = 11 digit NDC Code(e.g., LIN**N4*01234567891)• NDC Quantity• Bill the NDC Quantity using a metric decimal quantity administered to the patient asdefined in the NCPDP Billing Unit Standard. The quantity of each submitted NDCmust be a numeric value greater than zero. Decimal quantities must be submitted ifapplicable. Do not include any spaces (e.g., 10.25).• The 2410 Loop requires all three CTP segments. The segments are NDC Unit Price,NDC Quantity and Composite of Measure.• NDC Unit Price in Loop 2410, Segment CTP03, Element = Dollar Amount (0.00 isacceptable)• NDC Quantity in Loop 2410, Segment CTP04, Element = (Maximum length of 15 withimplied decimal)• Composite unit of measure in Loop 2410, Segment CTP05, Element = (e.g., UN, ML,GR, F2)221 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

BC - Blue CrossA - AvailityIG - ImplementationGuideBlank - Not AvailableSituational *Important Note: For Ancillary Providers, see Billing Requirements pg. 19- SRequired - RProvider S SLegend:Physician S RPurchase ServiceOperating S R ROther OperatingServicing Facility S S S S S S R R R R R RAttending S R R S R ROrdering Provider S S* SSupervising Provider S R RRendering Provider S R R S R R S R RReferring Provider S S S S* SBilling Provider R R R R R R S R R S R R R R R R R R R R R R R RPay To S R R S R RClaims Institutional Professional Institutional Professional Institutional Professional Institutional ProfessionalPROVIDER TYPES IG BC A IG BC A IG BC A IG BC A IG BC A IG BC A IG BC A IG BC AFlorida Blue NPI Attributes RequirementsNPI Taxonomy EIN (Tax ID) Zip + 4 DigitFlorida Blue 837P Companion Guide 2012VIII.23900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012NPI Attributes Technical Information837 Professional NPI Taxonomy Zip + 4 DigitPROVIDER TYPE IG BC Loop SegmentDataElement IG BC Loop SegmentDataElement IG BC Loop SegmentDataElementBilling Provider R R 2010AA NM1 09 S R 2000A PRV 03 S R2010AA N4 03Pay To Provider S S2010AB N4 03Rendering Provider S R2310B2420A NM1 09 S S2310AReferring Provider S S* 2420F NM1 09Ordering Provider S S* 2420E NM1 09SupervisingProvider S R2310D2420D NM1 092310B2420A PRV 03Purchase ServiceProvider S S 2420B NM1 09Service Facility S S2310C2420C NM1 09 S RLegend:R - RequiredS - SituationalBlank – N/A *Important Note: For Ancillary Providers, see Billing Requirements pg. 19IG - Implementation GuideBC - Blue Cross2310C2420C N4 03241 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837P Companion Guide 2012IX.Helpful Tips: How to Avoid Provider Identification Errors for Claimsinvolving National Provider Identifier (NPI) and Tax ID number.Below are reminders to help you reduce the number of WEBV040 and WEBV042 claimserrors displayed when claim data (or information) does not match informationregistered with Florida Blue.A. Billing Provider SectionThis section is used to provide information regarding the billing provider for servicesrendered. It should match the name written on the check or electronic funds transferfrom Florida Blue.i. OPTION 1: If you are registered as a group provider (PA, LLC, etc.) with FloridaBlue and you want to bill as a group provider, enter the appropriate group name,Tax ID number and the group NPI (type 2).0. THE MATCH: Group Name matches Group NPI matches Group Tax IDii. OPTION 2: If you are registered as an individual provider with Florida Blue andyou are billing as an individual provider, please enter your name, Social SecurityNumber and your individual NPI (type 1).0. THE MATCH: Individual Name matches Individual NPI matches IndividualSocial Security NumberB. Rendering Provider SectionThis section is used to provide information regarding who performed the services. It isthe provider who actually sees the patient.iii. OPTION 1: If you billed as an organization (PA, LLC, etc.) list the name of therendering individual provider and the rendering individual NPI.iv. OPTION 2: If you billed as an individual, do not list a rendering provider. Thiswould be redundant as the billing individual would be the same as the renderingindividual. Submitting redundant information can cause a different providercorrectable error.Below is an example to assist you in understanding the appropriate entry of billing andrendering provider information to reduce the number of returned claims.25900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012C. Billing as a Group Provider – OPTION 1If you are billing as a group provider (PA, LLC, etc.), the NPI must be the Group NPI (type2) along with the appropriate Tax ID number for the group.Please note that the Billing Section is for the entity BILLING for the services. TheRendering Provider Section is for the provider who PERFORMED the services.Correct Entry (THE MATCH):This example shows how the information submitted matches data registered withFlorida Blue. The Group Name matches Group NPI which matches Group Tax ID numberand all match Florida Blue provider files.261 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012Incorrect Entries (THE MISMATCH):Below are examples of information that will result in a mismatch of data causing aWEBV040 provider correctable error ultimately resulting in a delay inpayment. The mismatch is highlighted in red.Remember: Group Name = Group NPI = Group Tax ID NumberTo confirm how you are registered with Florida Blue, please call the Provider ContactCenter at (800) 727-2227, select option 5, and then option 2. If you would like toregister a different Tax ID number, please complete the Provider Information UpdateForm (sections 1 and 6.) A completed IRS confirmation letter must be included.271 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012D. Billing as an Individual Provider – OPTION 2If you are billing as an individual provider, the NPI must be the individual NPI (type 1)along with the appropriate Social Security Number. Do not enter a provider at all in therendering section when the billing and rendering provider is the same person.Submitting redundant information can cause a different provider correctable error.Correct Entry (THE MATCH):This example shows how the information entered matches data registered with FloridaBlue. Individual Name matches Individual NPI matches Individual Social SecurityNumber.Incorrect Entries (THE MISMATCH):Below are examples of information entered that will result in a mismatch of datacausing a delay in payment. The mismatch is highlighted in red.281 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012REMEMBER: Individual Name = Individual NPI = Individual Social Security NumberTo confirm how you are registered with Florida Blue, please call the Provider ContactCenter at (800) 727-2227, select option 5, and then option 2. If you would like toregister a different Tax ID number, please complete the Provider Information UpdateForm.(sections 1 and 6.) A completed IRS confirmation letter must be included.X. Tips for Sending Coordination of Benefits Information on Electronic Claims837 Professional Health Care ClaimsWhen Florida Blue is secondary, please remember to include coordination of benefits (COB)data on your claim as outlined below. All HIPAA mandated fields are required. The businessrequirements and corresponding 837 fields listed below are necessary to process COBinformation on Florida Blue claims.R =RequiredS=SituationalS837 Fields Business RequirementLoop 2320 CAS 01-19, asneededSubmission of other insurance payment information requiresclaim adjustment group codes and associated monetaryamounts. Please be sure to submit any differences betweenthe paid and charge amounts in the CAS segments. FloridaBlue requires the 837 to balance including the COB segments.R Loop 2320AMT 01AMT 02When Florida Blue is secondary, submit the primary insurerpayment information to support correct processing of COBinformation.RLoop 2430 CAS segmentsLoop 2430 SVD 02AMT01 – D is requiredAMT02 – Sum of all Line level Payment Amount minus anyClaim Level Adjustment amounts must balance to Claim levelPayment Amount.When Medicare is primary and Florida Blue is secondary,Florida Blue requires a line level adjustment reason code andpayment amount which must balance back to charge.291 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012XI.Communication / Connectivity Protocols Supported:Note: If you submit your transactions through Availity, please refer to the Availity EDI Guide.This section is specifically intended for trading partners who exchange transactions directly withFlorida Blue.Connectivity • Secure File Transfer via Internet• FTP via ISDN, Leased Lines, Frame Relay, VPNTest and Production URL https://securefile.BCBSFL.comEncryption MethodProtocols UsedClient examples are:Secure Socket Layer (SSL)• HTTPS/FTPS• HTTPS and your common Internet browsers (IE, Firefox, etc.) Port443 (default)• FTPS: Any FTP client capable of SSL encryption• Valicert ftp client• Cute-FTP• WS-FTP Pro• FileZilla• OthersFTPS Parameters • Port 21• Authentication: FTP over SSL (explicit) or FTP over TLS (explicit)• Active Mode• File retention is 72 hoursSSH Parameters • Use SFTP or SCP• Port 22• Authentication: user id and passwordFirewall MechanicsIf you are a behind a firewall make sure that your FTPS client passesthe Internet faceting IP address of the Server rather than the InternalIP. Failure to do so usually causes the communication break whenthe client tries to list the files available in the Server or during uploador download of files.301 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012

Florida Blue 837 P Companion Guide 2012XII.Trading Partner AgreementPlease contact Availity at 1 (800)-AVAILITY or www. Availity.com for your Trading Partner Agreement.311 Availity, LLC Is a multi-payer joint venture company. For more information or to register, visit Availity’s website atwww.availity.com.900-3398-1112005010X222A1Florida Blue December 2012