Response Files Operational Procedures
Response Files like 999 Functional Acknowledgement file will be generated within one business day. To verify if the file was accepted or rejected at this level, look for the IK5 and AK9 segments. If these two segments are followed by an ‘A’ the file was accepted. If these two segments are followed by an ‘E’ the file “accepted with errors” and will process onto the 277CA Claims Acknowledgement report. If the two segments are followed by an ‘R’ the file was rejected at this level. If the file is rejected at this level, the 277CA report will not follow.
The 277CA Claims Acknowledgement report may take up to 72 hours to post, depending on the content and complexity of the claims the original 837 file contained. The 277CA Claims Acknowledgement report (277CA) is to provide a claim-level acknowledgement of all claims received in the front-end processing system before claims are sent into IEHP claim processing system. The Rejected claims reported on the 277CA should be reviewed, corrected, and resubmitted. Claims accepted with errors will be reviewed by IEHP claims processors for completeness. The claim will either be processed or, if found to be incomplete, sent back in a letter explaining why it could not be processed. Accepted claims will be pushed through the claims processing system for payment evaluation.
IEHP shall place 999 and 277CA response files on the SFTP server in the ‘/claims/outbound/’ folder in the submitter’s home directory, (e.g. ‘/13/claims/outbound/’). Additionally, 835 Electronic Remittance Advice Transaction files can also be produced, but enrollment for 835 Electronic Remittance Advice must be requested. The 835 Electronic Remittance Advice Transaction file provides claim payment information in the HIPAA mandated ACSX12 005010X221A1 format. The 835 Electronic Advice Transactions is a standard transaction mandated by the Health Insurance Portability and Accountability Act (HIPAA) and is used to transfer payment and remittance information for adjudicated professional and institutional health care claims. The 835 returns payment information that is reported on paper EOB/PRAs Explanation of Benefits/Provider Remittance Advice to the provider or clearinghouse, in an electronic format The ERA/835 uses claim adjustment reason codes mandated by
HIPAA. 835 files are named with the submitter ID and the EFT/check number (e.g. ‘098’ & 6-digit payment ID, 098123456.R00) rather than an originally submitted claim file name as apayment may contain claims from multiple submissions. These files are also placed on the SFTP server in the ‘/claims/outbound’ folder in the submitter’s home directory.