336 WinCare User Guide User's Guide

Segment/Element Data

ISA01

ISA02

ISA03

ISA04

User Interface

Location

Notes

00 (no data in

ISA02) or 03

(Authorization data in ISA02)

EDI Receiver Screen under EDI Maintenance

Authorization

Information specified in the Implementation

Guide published by the

Receiver

Author information or blank

EDI Receiver Per IG

00 or 01, 00 if no meaningful info in

ISA04, and 01 if there is

EDI Receiver

Security Information EDI Receiver

Per IG,Qualifier for what is in ISA04

Per IG

Per IG ISA05 Qualifier for ISA06, often 30 for Fed Tax

ID or ZZ for mutually defined.

EDI Receiver

ISA06

ISA07

Interchange Sender

ID, Often Fed Tax

ID of Facility

EDI Receiver

Qualifier for ISA08, often 28, for Fiscal

Intermediary ID assigned by CMS

EDI Receiver

ISA08

GS02

Interchange Receiver

ID

EDI Receiver

Application Senders

Code

EDI Receiver

EDI Receiver GS03 Applications

Receiver Code

NM109 of NM1*41 Submitter NM1

Submitter ID

EDI Receiver

Submitter ID

NM103 of NM1*41 Submitter Name Bill Provider Screen

Per IG

Per IG

Per IG

Per IG, mutually agreed upon

Per IG, mutually agreed upon

This is the Submitter

ETIN (Electronic

Transmitter

Identification Number, by Trading Partner

Agreement) NM108 should be = 46 to say this is ETIN number.

EDI (Electronic Billing) 337

PER02 of PER*IC Submitter Contact

Person

Bill Provider Screen,

Contact Person

Who the Receiver should contact if there are problems with the transmission.

PER04 of PER*IC Submitter Contact

Telephone Number

Bill Provider Screen,

Telephone Area Code plus number

NM103 of NM1*40 Receiver Name

NM109 of NM1*40 ReceiverID

NM103 of NM1*85 Billing Provider

Name

EDI Receiver Screen,

Intermediary Name

Labeled Intermediary

Name on screen. Who this file is going to be sent to

ID of who we are sending this file to.

EDI Receiver Screen,

Receiver ID

Bill Provider Screen, Org

Name

Although this is the facility, by Trading

Partner Agreement it could be a different name still representing the facility.

NM109 of NM1*85 Billing Provider ID,

Billing Provider NPI number.

NM103 of

NM1*PR

NM109 of

NM1*PR

Payor Name

Payor ID

EDI Receiver Screen,

Billing Provider ID

Master Files, Payor

Definition, Paying

Agencies, Payor Name for Claims and EDI

Although this now is the

NPI (National Provider

ID for the facility), it was recently able to be specified by the

Receiver as to what this was in NM108, i.e. 24 for EIN, 34 for SSN etc., now NM108 is hard coded to 'XX'

In order for the Facility to allow for a custom

Payor name on their reports and for use in

WinCare, the actual

Payor name can be specified by Medicare or

Medi-Cal, different from what the facility likes to call the Payor.

Master Files, Payor

Definition, Paying

Agencies, CMS Payor ID

As far as we know, assigned by CMS to the payor and good for anyone we send the file to (i.e. all receivers)

338 WinCare User Guide User's Guide

NM103 of

NM1*PR (This occurs in loop

2330B, after the all the HI info, the

Physician names, and is used for

COB) It appears that only one other payor (the 2nd?) is put into the file per the spec.

Other Payor Name F50 of the UB Claim, but originally comes from the

Payor Name in paying agencies. Census entries specify which Payor is

2nd when the UB Claim is created.

We get this from F50 of the paper claim.

NM109 of

NM1*PR

(Loop 2330B for

COB - coordination of benefits)

Other Payor ID Upon creation of the UB

Claim, the 2nd and 3rd

Payor ID's of the Payors in the Paying Agencies

The value of this did not seem to be important for

Medicare and Medicaid

Claims for payors other are recorded in the Claim. than Medicaid as

When the EDI claim is created, the CMSPayorID is looked up out of the

Paying Agencies table. If secondary. In 5010, I am not yet sure if any receivers are going to really use the value we put in until COB becomes a reality. there is not a PayorID > 0 listed, then an attempt is made to find a payor in the paying agencies table that has a name that matches F50 of the UB

Claim and then the CMS

Payor ID of that payor is used.

C

H A P T E R

2 6

Payments Refunds

In This Chapter

Payments Refunds Main Screen ........................................ 341

Single Resident Payment ................................................... 343

Batch Payment and C/A ..................................................... 347

Customer Credits................................................................ 355

Lookup Transactions .......................................................... 358

Overview of 835 Electronic Remittance Advice Import .... 359

Payments From 835 ........................................................... 360

View 835 Exceptions ......................................................... 369

View Already Applied Payment Files and Logs ................ 370

339