EDI Claims Processing Guidelines (SummaCare)
Any claim submitted that contains more than 85 service lines will be split into two claims by SummaCare for payment. When submitting an 837 transaction for members after billing their other insurance sources, the other payer’s adjudication details that were provided on the 835 Remittance transaction must be supplied to SummaCare.
The other payer’s adjudication details, both at the line level and the claim level, are required to process the claim. Trading partners should review the Implementation Guides for both the 837 HealthCare Claim transaction and the 835 HealthCare Claim Payment/Advice transaction, plus the crosswalks provided to fully understand the COB process.
Sending Attachments or Paperwork to Support a Claim
SummaCare accepts supporting documentation by mail only. Illegible information will delay processing. All documentation and Attachment Cover Sheets must be received within 14 calendar days of the electronic transmission otherwise the claim will be denied.
Late Charges/Corrected Bills
The Claim Frequency Type Code located in segment CLM05-03 determines the processing of late charges or corrected bills.
- A late charge is indicated by placing a “5” in this field. Please do not combine the amount of the late charge with the amount of the original charge.
- A corrected bill is indicated by placing a “7” in this field.
SummaCare accepts all compliant data elements on the 837 Institutional Claim. Follow the points outlined below for consistent data format and content issues:
- All dates that are submitted on an incoming 837-claim transaction should be valid calendar dates in the appropriate format based on the respective qualifier.
- Future dates will be rejected.
- No decimals should be used in a diagnosis code.
- Monetary Amounts, Unit Amounts, and Numeric Values
- The transaction will be rejected if the monetary amounts do not balance.
- SummaCare accepts monetary amounts only in US dollars. If codes related to foreign currencies are used, the claim will be denied.
- Unit amounts must be in whole numbers only.
- Negative values for monetary or unit amounts may not be processed and may result in the claim being rejected if submitted in the following segments, Loop 2400, Loop 2320:
- SV203 Monetary amount – Line Item Charged Amount
- SV205 Quantity – Service Unit Count
- SV Monetary amount – Line Item Charge of Non-Covered Charge Amount
- AMT02 Monetary amount – COB Allowed Amount
- AMT02 Monetary amount – COB Payer Prior Payment
- Phone Numbers
- Telephone numbers should be presented as contiguous number strings. Do not use dashes or parenthesis markers. Area codes should always be used.
997 Acknowledgement will be returned at the file level. The 997 will return a status reflecting accepted,
rejected and accepted with error. 277CA will return a status reflecting each claim submitted in the 837