837 Professional and Institutional Claims Notes (Washington State Medicaid processing for Washington State HCA)

837 Professional and Institutional837 Professional and Institutional Claims implementation guides are represented for each mandated transaction and modified by authorized Addenda. When accepting 837 Encounters transactions from trading partners, HCA follows HIPAA standards. These standards involve Interchange (ISA/IEA) and Functional Group (GS/GE) Segments or “outer envelopes”.

All 837 Encounters Transactions should follow the HIPAA guideline. You can refer to the 837 Implementation Guide for ISA/IEA envelop, GS/GE functional group and ST/SE transaction specifications. The ISA/IEA Interchange Envelope, unlike most ASC X12 data structures has fixed field length. The entire data length of the data element should be considered and padded with spaces if the data element length is less than the field length.

Once the file is submitted by the trading partner and is successfully received by the ProviderOne system, a response in the form of TA1 and 999 acknowledgment transactions will be placed in appropriate folder (on the SFTP server) of the trading partner. The ProviderOne system generates positive TA1 and positive 999 acknowledgements, if the submitted HIPAA file meets HIPAA standards related to syntax and data integrity. For files, which do not meet the HIPAA standards a negative TA1 and/or negative 999 are generated and sent to the trading partner.

Encounters will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure (Strategic National Implementation Process (SNIP) type 1 and 2).

Currently, the 837P has one Addendum and the 837I transaction has two Addendum. These Addendum have been adopted as final and are incorporated into HCA requirements. An overview of requirements specific to the transaction can be found in the 837P and 837I Implementation Guides. Implementation Guides contain information related to: Format and content of interchanges and functional groups, Format and content of the header, detailer and trailer segments specific to the transaction, Code sets and values authorized for use in the transaction, Allowed exceptions to specific transaction requirements.

Transmission sizes are limited based on two factors:

  1. Number of Segments/Records allowed by HIPAA Standards
  2. HCA file size limitations HIPAA standards limits the size of the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. HCA limits a file size to 50 MB while uploading HIPAA files through the ProviderOne web portal and 100 MB through FTP.

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