837 Professional Healthcare Claim (Washington State Medicaid Trading Partners Requirements)
837 Professional Healthcare Claim guidelines can be used by members/technical staff of trading partners who are responsible for electronic transaction/file exchanges. Completion of the testing process must occur prior to submitting electronic transactions in production to ProviderOne.
Testing is conducted to ensure the following levels of HIPAA compliance:
1. Level 1 – Syntactical integrity: Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules.
2. Level 2 – Syntactical requirements: Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts, used and not used qualifiers, codes, elements and segments. It will also include testing for HIPAA required or intra-segment situational data elements, testing for non-medical code sets. Additional testing may be required in the future to verify any changes made to the ProviderOne system. Changes to the formats may also require additional testing.
The ProviderOne will use the following delimiters on outbound transactions:
- Data element separator – Asterisk ( * )
- Sub-element Separator – colon ( : )
- Segment Terminator – Tilde ( ~ )
Data Interchange Conventions When accepting 837 Healthcare Claim 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 Transactions should follow the HIPAA guideline. 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. 837 Healthcare Claims will be rejected if the file does not meet HIPAA standards for syntax, data integrity and structure.