HMSA EDI Mapping Guidelines (File, Functional Group, Transaction Set, and Claim Rejection)
HMSA EDI Mapping Guidelines are given for business partners transmitting electronic transactions to HMSA. HMSA EDI Mapping Guidelines cover the following points – File, Functional Group, Transaction Set, and Claim Rejection.
- A file level reject occurs when an error is detected in the interchange control header (ISA) or trailer (IEA) segment. A file level reject could also occur when there is a submission of a duplicate file. Following the correction of all errors, the file should be resubmitted.
- A functional group level reject occurs when there is an error detected in the functional group header (GS) or trailer (GE) segment. All transaction sets within the functional group are rejected. Following the correction of all errors, only the rejected functional group should be resubmitted.
- A transaction set level reject occurs when data within a transaction set (ST/SE) does not comply with the requirements stated in the HIPAA Implementation Guide. Only the transaction set(s) containing errors within a functional group are rejected. Following the correction of all errors, only the rejected transaction set should be resubmitted.
- A claim level reject occurs when data contained within the claim does not comply with the requirements stated in the HIPAA Implementation Guide, or business rules for claims submission. The 999 Acknowledgment will only report HIPAA errors. Both HIPAA errors and HMSA business errors will be reported on the Claims Rejected to Provider (CRTP) report. Rejected claims reported on the CRTP should be corrected and resubmitted.
- A request level reject (27x transaction) occurs when data contained within the request does not comply with the requirements stated in the Implementation Guide or business rules for eligibility, claim status, or authorization request. Errors will be reported in a 999.
Tax may be billed to the member only when the 835 contains a CAS adjustment segment using:
- Claim Adjustment Group Code = “PR”
- Claim Adjustment Reason Code = “137”
Tax cannot be billed to the member if CAS segment reflects any other claim adjustment group code (e.g. CO). For example:
- AS{PR{137{1.66~ – $1.66 tax may be billed to the member
- CAS{CO{137{2.40~ – Tax cannot be billed to the member.