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Wellmark Transaction/Code Set Compliance

October 16, 2003

820-Premium Payment
834-Member Enrollment and Maintenance
835-Electronic Remittance Advice
837I-Institutional claim
837D-Dental claim
837P-Professional claim
270/271-Eligibility Inquiry/Response
276/277-Claim Status Inquiry/Response
278-Preauthorization/Precertification/Referral

Yes.

No.

Format 834: Benefit Enrollment and Maintenance

Enrolled groups have an opportunity to simplify their enrollment process with the use of Electronic Transaction 834 - Benefit Enrollment and Maintenance.
 
This electronic format includes information on member demographics, changes in enrollment information, and allows a group to enroll, dis-enroll or re-enroll members electronically. The 834 format replaces many non-standard data formats now used and will become the industry standard.
 
Using the 834 simplifies the enrollment process, and includes all the fields Wellmark now uses on paper applications.

Transaction Rule Requirements

The standard transaction formats and their ANSI ASC designations under HIPAA-AS rules are:
  • Health claims - 837 Institutional, 837 Professional, and 837 Dental
  • Health care payments and remittance - 835
  • Coordination of benefits - 837 COB
  • Health claim status inquiry and response - 276 and 277
  • Enrollment or disenrollment in a health plan - 834
  • Eligibility verification and benefit inquiry and response - 270 and 271
  • Premium payments - 820
  • Referral certification and authorization - 278

The code sets specified by HIPAA-AS rules are:

Current Procedural Terminology (CPT-4)

Practitioner services

ICD-9-CM, Volumes 1 & 2

Diseases

Injuries

Other health problems

Impairments

Causes

ICD-9-CM, Volume 3

Diagnosis Management

Prevention Treatment

NDC

Drugs

Biologies

Current Dental Terminology (CDT-4)

Dental Services

HCPCS - Level 2

Physician Services

Physical Occupational Therapy

Radiology Services

Lab Tests

Other Medical Diagnostics Procedures

Hearing and Vision

Transportation Services

Prosthetic Devices

Medical Supplies

Orthotic Devices

Durable Medical Equipment

Under HIPAA-AS, providers must submit and carriers must accept only VALID codes from these national code sets. Wellmark Blue Cross and Blue Shield began over two years ago to eliminate "local" codes - codes designed by carriers for specific benefit processing.  The intent of the HIPAA-AS legislation is to ensure that only nationally recognized coding will be used to simplify the claims submission and adjudication process among carriers and providers.

Yes. Two common code sets not specified by the rules are: Anesthesiology Society of America (ASA) and the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) [note: although the DSM-IV is not designated, the information in these codes also is included in the ICD-9-CM codes which are specified by the HIPAA-AS rules.] The ASA and DSM-IV codes are not accepted as standard code sets.

No. HIPAA-AS does not require carriers to process claims or offer benefits to groups and individuals in any fixed manner.  However, the concept of accepting a standard claims format with standard codes does not prevent carriers from making unique adjudication decisions based on the variety of benefits programs available to the public.

No. If you do not send electronic transactions today, you are not required to begin. However, if you send any of the covered transactions electronically, you must follow the Transactions and Code Sets rules.

HIPAA-AS does not set any rules for paper claims. You can continue to send them as you do today.

The rules of HIPAA-AS do not change how a payer compensates providers for health care services. There should be no change to an operation's cash flow.

While the goal of HIPAA-AS is to standardize electronic transactions, there will still be some differences from payer to payer.

Testing and Implementing Transactions

Wellmark offers testing through the INet's Model Office system, which will provide front-end testing of the acceptance process for an electronic transaction. This testing option is available to all submitters and vendors. Wellmark also offers full system testing, including claim adjudication and electronic remittance advice, for key submitters.
Health claims - 837 Institutional, 837 Professional, and 837 Dental 
Testing for the claims transaction (ANSI 837) is available through INet.
This service provides the opportunity for you to check your test file against the ANSI 837 format and receive the reports produced from this test.
For instructions on sending the test claims file, see the INet Account Library article titled ANSI 837 Testing Instructions. Information regarding testing for other transactions will be provided as available.

Yes. Although your vendor will provide the ability for you to create the standard format, the transaction is not complete without your data. Testing by your vendor would be helpful.  However, a test sent from your system with your test data is preferred.

Wellmark suggests that testing of software include sufficient claims to fully test a system. This would include sample claims for each type of business supported by health care practitioners and facilities.

Separate ID numbers and passwords will be used for testing. Documentation for testing procedures will indicate user IDs, passwords, dial-up procedures and reporting expectations for the HIPAA-AS Transaction testing. Instructions for testing transactions can be found in INet Account Library article 1ANSI837.pdf, or you can call EC Solutions at 800-407-0267.