CMS 837I NOE Companion Guide

CMS

Companion Guide Transaction Information

Instructions related to the Non-Standard Use of

the 837 Health Care Claim: Institutional
Transaction as a Hospice Notice of Election
based on ASC X12 Technical Report Type 3
(TR3), version 005010A2

Companion Guide Version Number: 1.1

January 2018

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CMS 837I NOE Companion Guide

Preface
Companion Guides (CGs) may contain two types of data, instructions for electronic
communications with the publishing entity (Communications/Connectivity Instructions) and
supplemental information for creating transactions for the publishing entity while ensuring
compliance with the associated ASC X12 IG (Transaction Instructions). Either the
Communications/Connectivity component or the Transaction Instruction component must be
included in every CG. The components may be published as separate documents or as a single
document.

The Communications/Connectivity component is included in the CG when the publishing entity

wants to convey the information needed to commence and maintain communication exchange.

The Transaction Instruction component is included in the CG when the publishing entity wants to
clarify the IG instructions for submission of specific electronic transactions. The Transaction
Instruction component content is in conformance with ASC X12’s Fair Use and Copyright
statements.

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Table of Contents
Transaction Instruction (TI) ........................................................................................ 3

1. TI Introduction .......................................................................................................... 4
1.1 Background ........................................................................................................... 4
1.1.1 Overview of HIPAA Legislation................................................................ 4
1.1.2 Compliance according to HIPAA............................................................... 4
1.1.3 Compliance according to ASC X12 ........................................................... 4
1.2 Intended Use ......................................................................................................... 5

2. Included ASC X12 Implementation Guides ............................................................ 5

3. Instruction Table ....................................................................................................... 5

005010X223A2 Health Care Claim: Institutional....................................................... 6

4. TI Additional Information ...................................................................................... 12

4.1 Other Resources .................................................................................................. 12
4.2 Change Log .................................................................................................. 13

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Transaction Instruction (TI)

1. TI Introduction
1.1 Background
1.1.1 Overview of HIPAA Legislation
The Health Insurance Portability and Accountability Act (HIPAA) of 1996
carries provisions for administrative simplification. This requires the Secretary
of the Department of Health and Human Services (HHS) to adopt standards to
support the electronic exchange of administrative and financial health care
transactions primarily between health care providers and plans. HIPAA directs
the Secretary to adopt standards for transactions to enable health information
to be exchanged electronically and to adopt specifications for implementing
each standard
HIPAA serves to:
• Create better access to health insurance
• Limit fraud and abuse
• Reduce administrative costs

1.1.2 Compliance according to HIPAA

The HIPAA regulations at 45 CFR 162.915 require that covered entities not
enter into a trading partner agreement that would do any of the following:
• Change the definition, data condition, or use of a data element or
segment in a standard.
• Add any data elements or segments to the maximum defined data set.
• Use any code or data elements that are marked “not used” in the
standard’s implementation specifications or are not in the standard’s
implementation specification(s).
• Change the meaning or intent of the standard’s implementation
specification(s).

1.1.3 Compliance according to ASC X12

ASC X12 requirements include specific restrictions that prohibit trading
partners from:
• Modifying any defining, explanatory, or clarifying content
contained in the implementation guide.
• Modifying any requirement contained in the implementation guide.

1.1.4 Use for a Non-HIPAA Transaction

This Transaction Instruction uses a standard transaction format for the submission
of hospice Notices of Election (NOEs). The NOE is not a HIPAA-covered

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transaction. It does not meet the definition of a claim or encounter at 45 CFR §
162.1101 because it does not request payment or report health care services.

While the contents of this Transaction Instruction meet the compliance

requirements described in sections 1.1.2 and 1.1.3, this is a non-standard use of
837I Implementation Guide. Medicare-participating hospices may adopt the use
of this Transaction Instruction for NOEs on a strictly voluntary basis and as an
optional extension of their existing trading partner agreement with the Medicare
program and their Medicare Administrative Contractor.

Medicare encourages hospice to submit groups of NOEs in separate batch

transmissions from groups of claims. This practice may reduce the risk that
translator-level rejections related to NOEs, if they occur, could impact payments
to the hospice.

NOEs will receive 277CA acknowledgements.

1.2 Intended Use

The Transaction Instruction component of this companion guide must be used in
conjunction with an associated ASC X12 Implementation Guide. The instructions in
this companion guide are not intended to be stand-alone requirements documents.
This companion guide conforms to all the requirements of any associated ASC X12
Implementation Guides and is in conformance with ASC X12’s Fair Use and
Copyright statements.

2. Included ASC X12 Implementation Guides

This table lists the X12N Implementation Guide for which specific transaction
Instructions apply and which are included in Section 3 of this document.

Unique ID Name
005010X223A2 Health Care Claim: Institutional (837)

3. Instruction Table
This table contains rows for where supplemental instruction information is located. The
order of table content follows the order of the implementation transaction set as presented
in the corresponding implementation guide.

Category 1. Situational Rules that explicitly depend upon and reference knowledge of the
transaction receiver's policies or processes.

Category 2. Technical characteristics or attributes of data elements that have been

assigned by the payer or other receiving entity, including size, and character sets
applicable, that a sender must be aware of for preparing a transmission.

Category 3. Situational segments and elements that are allowed by the implementation guide
but do not impact the receiver’s processing. (applies to inbound transactions)
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Category 4. Optional business functions supported by an implementation guide that an entity
doesn't support.

Category 5. To indicate if there needs to be an agreement between PAYER and the

transaction sender to send a specific type of transaction (claim/encounter or specific kind of
benefit data) where a specific mandate doesn’t already exist.

Category 6. To indicate a specific value needed for processing, such that processing may
fail without that value, where there are options in the TR3.

Category 7. TR3 specification constraints that apply differently between batch and real- time
implementations, and are not explicitly set in the guide.

Category 8. To identify data values sent by a sender to the receiver.

Category 9. To identify processing schedules or constraints that are important to

trading partner expectations.

Category 10. To identify situational data values or elements that are never sent.

005010X223A2 Health Care Claim: Institutional

Submitted as a Hospice Notice of Election
(NOE)

Loop
ID Reference Name Codes Notes/Comments Category
Errors identified for business level edits 9
performed prior to the SUBSCRIBER
LOOP (2000B) will result in immediate
file failure at that point. When this
occurs, no further editing will be
performed beyond the point of failure.
The billing provider must be associated 9
with an approved electronic submitter.
NOEs submitted for billing providers that
are not associated to an approved
electronic submitter will be rejected.
Contractor will convert all lower case 2
characters submitted on an inbound 837
file to upper case when sending data to
the Medicare processing system.
Consequently, data later submitted for
coordination of benefits will be

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Loop
ID Reference Name Codes Notes/Comments Category
Only loops, segments, and data 9
elements valid for the HIPAA
Institutional Implementation Guides
will be translated. Submitting data not
valid based on the Implementation
Guide will cause files to be rejected.
Medicare requires the National Provider 6
Identifier (NPI) be submitted as the
identifier for all NOEs. NOEs submitted
with legacy identifiers will be rejected.

National Provider Identifiers will be 2

validated against the NPI algorithm.
NOEs which fail validation will be
rejected.
All dates that are submitted on an 2
incoming 837 transaction must be valid
calendar dates in the appropriate format
based on the respective qualifier.
Failure to submit a valid calendar date
will result in rejection of the NOE or
the applicable interchange
(transmission).
ISA05 Interchange ID 28, ZZ Contractor will reject an interchange 6
Qualifier (transmission) that does not contain 28
or ZZ in ISA05
ISA06 Interchange Sender Contractor will reject an interchange 6
ID (transmission) that does not contain a
valid ID in ISA06.
ISA07 Interchange ID 28, ZZ Contractor will reject an interchange 6
Qualifier (transmission) that does not contain 28
or ZZ in ISA07.
ISA12 Interchange Control Contractor will reject an interchange 6
Version Number (transmission) that does not contain
00501 in ISA12.
Contractor will only process one 4
transaction type (records group) per
interchange (transmission); a submitter
must only submit one GS-GE
(Functional Group) within an ISA-IEA
(Interchange).
Contractor will only process one 4
transaction type per functional group; a
submitter must only submit one ST-SE
(Transaction Set) within a GS-GE
(Functional Group).
GS03 Application Contractor will reject an interchange 6
Receiver’s Code (transmission) that is submitted with an
invalid value in GS03 (Application
Receivers Code) based on the contractor
definition.
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Loop
ID Reference Name Codes Notes/Comments Category
GS04 Functional Group Contractor will reject an interchange 6
Creation Date (transmission) that is submitted with a
future date.
Contractor will only accept claims and 4
NOEs for one line of business per
transaction. Claims submitted for
multiple lines of business within one
ST-SE (Transaction Set) will cause the
transaction to be rejected.
ST01 Transaction Set 837 Trading partners acknowledge that 5
Identifier Code although ‘837’ is the submitted in this
data element, an NOE is not a health care
claim under the HIPAA definition.
ST02 Transaction Control Contractor will reject an interchange 6
Set (transmission) that is not submitted with
unique values in the ST02 (Transaction
Set Control Number) elements.
BHT02 Transaction Set 00 Transaction Set Purpose Code (BHT02) 6
Purpose Code must equal '00' (ORIGINAL).
BHT06 Claim/Encounter CH Claim or Encounter Indicator (BHT06) 6
Identifier must equal 'CH' (CHARGEABLE). This
is because the NOE is simulating a claim,
not because any charges being made.

1000A NM109 Submitter ID Contractor will reject an interchange 5

(transmission) that is submitted with a
submitter identification number that is
not authorized for electronic claim
submission.
1000B NM103 Receiver Name Contractor will reject an interchange 5
(transmission) that is not submitted with
a valid Part A MAC name (NM1).
1000B NM109 Receiver Primary Contractor will reject an interchange 5
Identifier (transmission) that is not submitted with
a valid Part A MAC code (NM1). Each
individual Contractor determines this
2000B HL04 Hierarchical Child 0 The value accepted is “0”. Submission 6
Code of “1” will cause your file to reject.

2000B SBR01 Payer P Submit all NOEs as “P” for primary, 6

Responsibility since payer sequence is not relevant to
Sequence Number identifying an election.
Code
2000B SBR02, Subscriber For Medicare, the subscriber is always 6
SBR09 Information the same as the patient (SBR02=18,
SBR09=MA). The Patient Hierarchical
Level (2000C loop) is not used.
2010AC Loop PAY TO PLAN Must not be present. Submission of this 4
Rule LOOP loop will cause your NOE to reject.
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Loop
ID Reference Name Codes Notes/Comments Category
2010BA NM102 Subscriber Entity 1 The value accepted is 1. Submission of 6
Type Qualifier value 2 will cause your NOE to reject.
2010BA NM108 Subscriber MI The value accepted is “MI”. Submission 6
Identification Code of value “II” will cause your NOE to
Qualifier reject.
2010BA NM109 Subscriber If HICN: 6
Identification Code Must be in the format of:
AAANNNNNNNNN or ANNNNNN or
AANNNNNN or AANNNNNNNNN or
AAANNNNNN or NNNNNNNNNA or
NNNNNNNNNAA or
NNNNNNNNNAN
(“A” - alpha
character, “N” - numeric digit).

If MBI:
Must be 11 positions in the format of:
C A AN N A AN N A A N N
("C" represents a constrained numeric 1
thru 9, "A" represents alphabetic
character A - Z but excluding S, L, O, I,
B, Z, "N" represents numeric 0 thru 9
and "AN" represents either "A" or "N".)

Submission of other formats will cause

your NOE to reject.
2010BA DMG02 Subscriber Birth Must not be a future date. Must be 6
Date present.
2010BA REF – SUBSCRIBER Must not be present. Submission of this 4
Segment SECONDARY segment will cause your NOE to reject.
Rule IDENTIFICATION
2010BB NM108 Payer Identification PI The value accepted is “PI”. Submission 6
Code Qualifier of value “XV” will cause your NOE to
reject.
2010BB REF – PAYER Must not be present. Submission of this 4
Segment SECONDARY segment will cause your NOE to reject.
Rule IDENTIFICATION

2010BB REF – BILLING Must not be present. Submission of 4

Segment PROVIDER this segment will cause your NOE to
Rule SECONDARY reject.
IDENTIFICATION
2000C HL – PATIENT Must not be present. Submission of this 4
Segment HIERARCHICAL segment will cause your NOE to reject.
Rule LEVEL
2000C PAT – PATIENT Must not be present. Submission of this 4
Segment INFORMATION segment will cause your NOE to reject.
Rule

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Loop
ID Reference Name Codes Notes/Comments Category
2010CA Loop PATIENT NAME Must not be present. Submission of this 4
Rule LOOP loop will cause your NOE to reject.
2300 CLM02 Total Submitted NOEs are submitted with a zero charge 8
Charges amount.

2300 CLM05 - Facility Type Code 81, 82 Must identify the facility type as a 6
1 hospice
2300 CLM05-3 Claim Frequency A, B, C, Must report a valid NUBC code 6
Type Code D, E representing an NOE or NOE-related
transaction.
2300 DTP03 Admission Date Must not be a future date. 6
2300 CL102 Admission Source 1 Not normally required by an NOE, but 6
Code required by the 837I format. Submit a
default value of ‘1.’

2300 CL103 Patient Status Code 30 Not normally required by an NOE, but 6
required by the 837I format. Submit
a default value of ’30.’

2300 CN1 – CONTRACT Must not be present. Submission of this 4

Segment INFORMATION segment will cause your NOE to reject.
Rule
2300 REF – PAYER CLAIM Must not be present. Submission of this 4
Segment CONTROL segment will cause your NOE to reject.
Rule NUMBER

2310A REF – ATTENDING Must not be present. Submission of this 4

Segment PROVIDER segment will cause your NOE to reject.
Rule SECONDARY
IDENTIFICATION
2400 SV2 INSTITUTIONA Not normally required by an NOE, 6
segment L SERVICE but required by the 837I format.
LINE Submit a single SV2 segment with
the default values listed below.

2400 SV201 Product/Service 0650 Submit revenue code 0650 (Hospice 6

ID Services – General Classification)
2400 SV202-1 Product or Service HC Submit qualifier HC. 6
ID Qualifier

2400 SV202-2 Product/Service Q5009 Not normally required by an NOE, 6

ID but required by the 837I format.
Submit HCPCS Q5009 since the
hospice site of service may not be
determined at the time of
submission.

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Loop
ID Reference Name Codes Notes/Comments Category
2400 SV202-7 Description NOE Not normally required by an NOE, 6
but required by the 837I usage notes
since SV202-2 contains an
unspecified code. Any string of data
satisfies the requirement.
Recommended value – “NOE.”

2400 SV203 Monetary Amount Submit a zero charge amount. 6

2400 SV205 Quantity 1 Submit 1 unit. 6

2400 DTP03 DATE - SERVICE Must not be a future date. 6

DATE

The instructions in the table above supplement existing Medicare guidance on submission of NOEs in Pub. 100-04,
chapter 11, section 20, which satisfy many other required fields on the 837I. Additional fields may be required by the
837I claim which can be completed based entirely on instructions in the TR3 itself.

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4. TI Additional Information
4.1 Other Resources
The following Websites provide information for where to obtain
documentation for Medicare adopted EDI transactions, code sets
and additional resources during the transition year.

Resource Web Address

ASC X12 TR3 Implementation Guides http://store.x12.org
Washington Publishing Company http://www.wpc-
Health Care Code Sets edi.com/content/view/711/401/
Central Version 005010 and D.0 https://www.cms.gov/Regulations-
Webpage on CMS website and-Guidance/Administrative-
Simplification/Versions5010andD0/ind
ex.html
Educational Resources (including MLN https://www.cms.gov/Regulations-
articles, fact sheets, readiness and-Guidance/Administrative-
checklists, brochures, quick reference Simplification/Versions5010andD0/4
charts and guides, and transcripts from 0_Educational_Resources.html
national provider calls)
Dedicated HIPAA 005010/D.0 Project http://www.cms.gov/MFFS5010D0/
Web page (including technical
documents and communications at
national conferences)
Frequently Asked Questions https://questions.cms.gov/

To request changes to HIPAA adopted http://www.hipaa-dsmo.org/

standards

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4.2 Change Log

Version Date Change Summary

1.0 September 2017 Original publication of this Guide.

1.1 January 2018 Added data element SV202-7 to the Instruction Table.
Revised Loop 2010AA, data element NM109 to include format
information for reporting an MBI identifier.

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