CMS-1500 Forms, Tutorials & Electronic Claims ANSI-837 EDI Setup & Overrides

This article explains how to customize paper CMS-1500 forms & electronic claim files (plain text and ANSI-837 5010) so that you can correctly submit claims to insurance carriers via paper, direct electronically or to clearinghouses.  Also see… Printable View Printable View


Insurance Carrier specific (all doctors) overrides for HCFA-1500

ChiroPulse365 version x.1465+ contains improvements in setting up carrier specific overrides to accommodate changes a certain insurance carrier still wants. For example if a carrier wants only 4 ICDs with the new CMS-1500 2014 form that allows 12 ICDs. Read the info info below to learn about insurance & clearinghouse customizations & overrides.

NOTE – remember that for each treating and invoice doctor (and the clinic/group) you must setup PINs for each insurance carrier in order to properly submit insurance claims (paper HCFA or electronic ANSI-837). For example some carriers want your NPI in additional boxes or fields. See the CMS-1500/HCFA Helper in Patient Tab of ChiroPulse365 to review the CMS-1500 boxes and ANSI loops. In addition to the PIN overrides, doctor setup & carrier setup, ChiroPulse365 offers even more customization required by pesky carriers 🙂

The Insurer Editor the OVERRIDE CMS box allows you to customize CMS-1500/EDI output for all claims for a certain Insurer. This makes it very easy to correct claims and stay up to date (for proper submission and reimbursement). Just click the blue text link to see all the overrides available.

CMS-1500 Override Logic (Paper & Plain Text EDI)

For Plain Text EDI & Paper Print CMS-1500 overrides allow you to omit data from certain boxes for & make small tweaks demanded by some insurers. Here is how:

  • Edit an Insurer – ie. from Insurer Tab, double-click to edit an insurer
  • Click OVERIDE-CMS in the insurance carrier editor, select overrides & save.
InsOverride1

CLICK SETUP OVERRIDES BLUE TEXT

insOverride2

SELECT ANY OVERRIDE THAT APPLIES TO THE CARRIER

Master List of CMS-1500Print Form and Plain Text EDI Overrides per Carrier

  • Box-4 remove all info for this carrier (x4)
  • Box-7 remove all info name, address, state, zip, phone, etc. for this carrier (x7)
  • Box-9A – remove MGAP prefix for this carrier (x9amgap)
  • Box-14 QUAL insert “431” for all CMS-1500 2014 Paper & Print Image files (14q-431)
  • Box-21 replace decimal with space ICD.00 to ICD 00 – removes the period in the ICDs & replaces it with two spaces (21sp)
  • Box-24A use 2 digit year in MM DD YY  – uses 2 digit year (not YYYY) in Box-24a  “MM DD YY” for example (24ayy)
  • Box-24E always use only 1 or A – always uses only the “1” or “A” in box24e even with regardless of the # of ICDs or state specific settings (24e1)
  • Box-24E use only the first 4 ICD pointers uses only the first four pointers ABCD not ABCDEF or CDEF not CDEFGH  in box24e for CMS-1500 2014 (02-12) regardless of the amount of ICDs pointed to the code and the state specific settings. (i.e. Anthem requirement). (24e4)
  • Box-24E always use all ICDs – always uses all the assigned ICDs, regardless of state-specific requirements (24eAll)
  • Box-24E remove commas between ICDs – remove commas between ICDs in Hcfa box-24e. State logic applies also where certain states want only the 1st ICD. (24enc)
  • Box-24 replaces decimal with two spaces – remove decimal & replaces it with two spaces 24fsp
  • Box-24I removes top info (plain text only) – remove top info from Box-24i from Plain Text EDI Only files. (x24it)
  • Box-24j remove top info for this carrier  (x24jt)
  • Box-24J removes bottom  info for this carrier  (x24jb)
  • Box-30 removes all info  for this carrier (x30)
  • Box-32A remove all info for this carrier (x32a)
  • Box-32B remove all info for this carrier  (x32b)
  • Box-33A remove all info for this carrier (x33a)
  • Box-33B  remove all info for this carrier (x33b)
  • na11c – uses the carriers ANSI x2 EDI “Submittor ID” field and inserts that in box-11c as required for ActivHealth or other clearinghouses/carriers.
  • paypre – uses the insurers carriers ANSI x12 EDI “Payor” field and inserts it in the upper right line in front of the Insurance Carrier’s Name/return address as required for ActivHealth or other clearinghouses/carriers.
  • 2310A always include Referring Physician info. If not entered in Claim Wizard page-2 the Rendering Physician’s info will be used

DIRECT CARRIER DIRECT SUBMISSION ANSI837 OVERRIDES (note clearinghouse overrides will override these settings)

  • 2310B-REF2 Allow “XX in Loop for clearinghouse (carrier direct submission)
  • 2320 AMT-D inclusion to 2nd carriers if present (2320amtd) when submitting direct to carrier

For example, a NY insurer might use several overrides: x24jt,x24jb,x32a,x32

For those who print paper CMS-1500 claims it is very useful to use the windowed envelopes designed for HCFA-1500 Claim Forms. These are available from Medical Arts Press. 800-328-2179
» Standard Envelopes (with or without return address) #14145
» Jumbo envelopes (with return address imprint) #14147
» Jumbo envelopes (without imprint for return address) #24147

If you are having trouble writing EDI files or viewing EDI files created please review this article Electronic Claims & ANSI Start to Finish Tutorial – click here


ANSI-X12 837 PRO EDI Customizations

You can override ANSI-837 5010 file output to match the needs of any Clearinghouse/carrier. Clearinghouse Editor is where you define all entities (clearinghouses &/or carriers) that will accept electronic claim submissions. Open Clearinghouse Editor from Insurer Tab [Clearinghouse Setup] or Utility menu or Setup Wizard.

From Clearinghouse Editor select an existing clearinghouse or create a new clearinghouse for 837-pro ANSI EDI output . Enter the basic info then press [Set ANSI-EDI Customizations] to setup more overrides.

Legacy ANSI Overrides

In addition to the dozens of overrides above, there remains a “legacy” EDI customization available to remove TOS Box-24C info from SV106 Value. To use this override, enter the text shown below in BOLD INCLUDING both brackets:

<sv106r,YOUR-TEXT-HERE> replace loop with text of your choice
<sv106x,>   delete loop entirely
<sv106p,YOUR-TEXT-HERE> prefix to add text of your choice before the standard loop data
<sv106s,YOUR-TEXT-HERE> suffix to add text of your choice after the standard loop data

 

Common mistakes & quirks that might cause EDI rejection:

TOS (HCFA box 24c) incorrectly used (on doctor default, claim default then Visit Wizard/ledger items. SV1 Loop 6 (i.e. SV106). Some insurers have required (or this can be optionally included in a paper claim without a rejection) the numeral “9” or “3” in Box 24C. However many insurers do not accept the TOS values and must be deleted in order for the claim to be accepted electronically. In Chiropulse the “9’s” must be deleted not only in the Claim itself, but also on each individual CPT code saved to the patient’s ledger.  To correct this use the above insurer or clearinghouse flag to remove the TOS entry for the claim so that no new visits will have an incorrect TOS entry then edit each visit line item using the corrector no TOS value.

InsuranceCarrier only allows Transmission Type Code 004010X098A1. Your file has a Transmission Type Code of 004010X098DA1. Your Clearinghouse and/or insurance carrier is set to “test mode” which uses a specific transmission code 004010X098DA1.
To correct: Edit your clearinghouse turn off “test mode” and/or also edit your insurance carrier (ansi x12 button) turning off “test mode”. Then recreate & resubmit your claims in Invoice Wizard.

Loop2000A PRV02 – Sometimes when submitting claims from the individual doctors (not the Group) a clearinghouse wants PXC in this loop/segment.  In this case simply use the Clearinghouse “Set ANSI Customization & Override” and enter PXC then save the clearinghouse & recreate the EDI file then resubmit the EDI file.

EDI with WI Medicaid ForwardHealth & some other clearinghouse claims are being rejected because the taxonomy code is in Loop 2010AA and the taxonomy code are required in Loop2000A PRV segment. The Taxonomy code “111N00000X” is set/used in Dr. Editor. in the BILLING PIN TYPE field on the right and the field directly below is “ZZ”
To correct: In the PIN/OVERRIDES for this insurer please verify the ATTENDING PIN (loop 2310B shaded portion) is set as required by your clearinghouse. Please set it to blank (24jk box) & none (24i box) for the Group & individual Doctors then regenerate the 837. Some users billing from the GROUP/OFFICE are using the Taxonomy code along with ZZ qualifier directly in the PIN/Override window.

Box14 Claim Wizard Current Illness date missing so that LOOP 2300 element/section DTP01 is coded 431 (onset of current illness) instead of code 454 (initial treatment date). Fix by simply entering the Box14 Current Illness Date in Claim Wizard page-2 & recreating the EDI file.