Attachment Ib 837D CCN Next Gen Companion Guide.pdf

PRE-DECISIONAL

DEPARTMENT OF VETERANS AFFAIRS

INTEGRATED VETERAN CARE (IVC)

HIPAA Transaction - Standard Companion Guide Health Care Claim: Dental

Based on ASC X12 version 005010x224A3 (837 COB Dental)

Community Care Network 005010x224A3 Coordination of Benefits Invoicing X12 837D

August 2025

Document Information Version History

Version Date Version Description

1.0 08/01/2025 Document creation

Disclosure Statement Copyright 2025 by the Department of Veterans Affairs (VA) Integrated Veteran Care (IVC) health care programs. All rights reserved. It may be freely redistributed in its entirety provided that this copyright is not removed. It may not be sold for profit or used in commercial documents without the prior written permission of the copyright holder. This document is provided “as is” without any expressed or implied warranty. Note that the copyright on the underlying Accredited Standards Committee (ASC) X12 Standards is held by the Data Interchange Standards Association (DISA) on behalf of ASC X12.

Preface This Companion Guide to the v5010 ASC X12N Implementation Guides and associated errata adopted under HIPAA clarifies and specifies the data content when exchanging electronically with the Department of Veterans Affairs (VA) Integrated Veteran Care (IVC) health care programs.

Transmissions based on this companion guide, used in tandem with the v5010 ASC X12N Implementation Guides, are compliant with both ASC X12 syntax and those guides. This Companion Guide is intended to convey information that is within the framework of the ASC X12N Implementation Guides adopted for use under HIPAA. The Companion Guide is not intended to convey information that in any way exceeds the requirements or usages of data expressed in the Implementation Guides.

Table of Contents

Disclosure statement

Preface

1.0 Introduction

1.1 Scope

1.2 Overview

1.3 References

2.0 Getting Started

2.1 Working with VA IVC Health Care Programs

2.2 Trading Partner Registration

3.0 Testing with the Payer

3.1 Testing

4.0 Connectivity with the Payer/ Communications

Process Flows

4.1 Transmission Administrative Procedures

4.2 Re- Transmission Procedure

4.3 Communications Protocol Specifications

5.0 Contact Information EDI Customer Service

5.1 EDI Technical Assistance

5.2 Veterans’ Health Administration (VHA) Customer Service Number

5.3 Applicable Websites/ E-Mail

6.0 Control Segments/ Envelopes

6.1 ISA-IEA

6.2 GS-GE

6.3 ST-SE

7.0 Payer Specific Business Rules and Limitations

8.0 Acknowledgements and/or Reports

8.1 999 Acknowledgements

8.2 Reconciliation Report

9.0 Trading Partner Agreements

10.0 Transaction Specific Information

1.0 Introduction

This companion guide is intended to assist in development and deployment of transmitting X12 837 Coordination of Benefits (COB) Health Care Professional Claims to support the Integrated Veteran Care (IVC) Community Care Network (CCN). Coordination of Benefits refers to those claims that are submitted by Community Care Network Third-Party Administrator (CCN TPA) to IVC for reimbursement. The companion guide serves as an addendum to any technical documentation supplied by the health care clearinghouse when establishing a trading partner agreement.

The VA IVC follows the ASC X12N/005010X224A3 Health Claim: Dental (837D) Technical Report Type 3 (TR3) documentation and does not introduce any additional segments or limitations in segment data in the transmission.

1.1 Scope

This document covers business and technical processes enacted by the VA IVC Third Party Administrator which vary from expectations governed by the 837 Dental TR3 when processing ASC X12N/005010X224A3, Health Claim: Dental transactions.

1.2 Overview

This document is intended to supplement the 837 TR3 and any additional Errata guides published by the Accredited Standard Committee and any additional companion guide supplied by the contracted Healthcare Clearing House contracted to serve the VA IVC. All requirements are intended to improve the facilitation of EDI transmissions and notify trading partners of EDI rules unique to the VA IVC EDI processing and business environment.

CCN TPA -to- IVC Payer EDI

Step 1. CCN TPA will create an 837 COB with adjudication results and send it to the VA via the

HCCH.

• CCN TPA takes the information about subscribers, and places it in the appropriate fields in the Subscriber Loop ID-2000B.

• CCN TPA places adjudication results in the appropriate Loop ID-2320 and/or Loop ID-2430 based on Business Usage section 1.4.1 in the TR3.

• In creating the 837 COB, the CCN TPA takes the information about the Veteran (subscriber) and places it in Loops ID-2320/2330.

Step 2. The CCN TPA sends the 837D COB batch to the VA

Step 3. The VA receives the 837D COB transaction from the CCN TPA and returns an X12 999

1.3 References

The 837D implementation guide (TR3) can be purchased at: https://x12.org/

The CAQH COR Payer Operating rules can be found at: https://www.caqh.org/core/operating-rules

2.0 Getting Started

2.1 Working with VA IVC Health Care Programs

To initiate EDI exchange with the VA IVC, an agreement on connectivity with the EDI clearinghouse contracted to support the VA IVC must first be finalized. Once decisions regarding connectivity between the TPA clearinghouse and the IVC clearinghouse are made, they will be communicated to the Payer EDI Team.

3.0 Testing with the Payer

3.1 Testing

All payer testing of a new trading partnership must be coordinated with the HCCH. The VHA will conduct end-to-end testing from the CCN TPA through the HCCH to the VHA prior to Production. This will include the return of X12 999 acknowledgement back through the connections.

https://x12.org/ https://www.caqh.org/core/operating-rules

4.0 Connectivity with the Payer/ Communications

Process Flow

VA Parallel with HCCH as source of all transactions to VA

TP

A

HC

CH

CC

N

P ro vi de r

TP

A

VA

VA

H

CC

H

Start Sends claim to

HCCH

Sends a copy of the batch to both the TPA and VA

TPA 277CA

process

Provider Receives

277CA

End

HCCH creates batch for single

Payer ID

VA Process Store 837 batch (F.E.E., EPRS, CDR)

277CA sent to Provider and VA

HCCH Pass through 277CA

TPA Adjudicate claim

TPA creates and send 835

TPA creates and send 837COB for reimbursement

835 sent to Provider and VA

Provider Receives

VA Receives pass through Provider

837COB sent to

VA

VA Receives

837COB

VA verifies and sends 277CA for

837COB

VA creates final disposition and sends 835

TPA recieves 835 for 837COB

TPA receives 277CA for 837COB

HCCH pass thru

VA Receives Provider 835

VA Receives 277CA

4.1 Transmission Administrative Procedures

All timing and transmission of EDI communication is to be coordinated with the Health Care Clearing House. Details will be agreed upon in a signed Interface Control Document (ICD).

4.2 Re- Transmission Procedure

Retransmissions of EDI, regardless of cause, should be performed within the bounds of coordination with the Health Care Clearing House.

4.3 Communications Protocol Specifications

All communication should be coordinated with the clearinghouse contracted to the VA IVC.

5.0 Contact Information EDI Customer Service

5.1 EDI Technical Assistance

All EDI technical assistance should be coordinated with the clearinghouse contracted to the VA IVC.

Email groups for VA transmission inquiries: CCPP-PST@va.gov

5.2 Veterans’ Health Administration (VHA) Customer Service Number Additionally, Customer Service Phone Number: Community Care Communication Center (C4) (formerly known as VA Fee): 1-877-881- 7618 mailto:CCPP-PST@va.gov

5.3 Applicable Websites/ E-Mail

Homepage for iEDI Clearinghouse: https://www.optum.com

Homepage for the Department of Veterans Affairs: https://www.VA.gov

Homepage for the VA IVC: https://www.VA.gov/communitycare

Email group for Integrated Veteran Care Payer EDI Team: VHAOIVCPMDPayerEDI@va.gov

Email groups for VA transmission inquiries: CCPP-PST@va.gov

CCRS POC Email Anil Kowatra Anil.Kowatra@va.gov Brendan Hoar Brendan.Hoar@va.gov Elizabeth Curfman Elizabeth.Curfman@va.gov Eric Budde Eric.Budde@va.gov Jacquilyn Kilo Jacquilyn.Kilo@va.gov Jennifer DaSilva Jennifer.DaSilva@va.gov Lam Ly Lam.Ly@va.gov Michael Larson Michael.Larson2@va.gov https://www.optum.com/ https://www.va.gov/ https://www.va.gov/communitycare mailto:CCPP-PST@va.gov mailto:Anil.Kowatra@va.gov mailto:Brendan.Hoar@va.gov mailto:Elizabeth.Curfman@va.gov mailto:Eric.Budde@va.gov mailto:Jacquilyn.Kilo@va.gov mailto:Jennifer.DaSilva@va.gov mailto:Lam.Ly@va.gov mailto:Michael.Larson2@va.gov

6.0 Control Segments/ Envelopes

6.1 ISA-IEA

The ISA and IEA values for the 837D COB batches sent from the CCN TPA to the IVC HCCH will be decided between the HCCH and the CCN TPA. The VA has their own agreement with the HCCH as to how the Sender/Receiver IDs will be populated on the HCCH to VA incoming 837D batch.

6.2 GS-GE

The GS and GE values for 837D COB batches sent from the CCN TPA to the IVC HCCH will be decided between the HCCH and the CCN TPA. The VA has their own agreement with the HCCH as to how the Sender/Receiver IDs will be populated on the HCCH to VA incoming 837D batch.

6.3 837 Envelope Format

EDI 837

File Type: 837 Dental 837 Professional 837 Institutional

Payer Export Payer ID:

NM1 PR=Qual in 09 Segment

2320 SBR P (VACCN)

VACCN

Data Element Separator Delimiter:

Loop 2320

Repetition Separator: ̂ ̂ ̂ Component Element Delimiter: : : :

Segment Terminator Delimiter: ~ ~ ~ ISA01 value: 0 0 0 ISA02 value: spaces spaces spaces ISA03 value: 0 0 0 ISA04 value: spaces spaces spaces ISA05 value: ZZ ZZ ZZ ISA06 value: TPA HCCH ID TPA HCCH ID TPA HCCH ID ISA07 value: ZZ ZZ ZZ ISA08 value: VACCN VACCN VACCN ISA09 value: yymmdd yymmdd yymmdd ISA10 value: hhmm hhmm hhmm ISA11 value: $ $ $ ISA12 value: 00501 00501 00501 ISA13 value: Unique ID Unique ID Unique ID ISA14 value: 1 1 1 ISA15 value: P P P ISA16 value: : : :

GS01 value: HC HC HC GS02 value: match ISA06 TPA HCCH ID TPA HCCH ID TPA HCCH ID GS03 value: match ISA08 VACCN VACCN VACCN GS04 value: yyyymmdd yyyymmdd yyyymmdd GS05 value: hhmm hhmm hhmm GS06 value: Unique ID Unique ID Unique ID GS07 value: X X X GS08 value: 005010X224A2 005010X222A1 005010X223A2

1000A NM103: VACCN VACCN VACCN

1000A NM109: VACCN VACCN VACCN

1000B NM103: VHA Community

Care Network VHA Community Care Network

VHA

Community Care Network

1000B NM109: CCN Payer ID CCN Payer ID CCN Payer ID

7.0 Payer Specific Business Rules and Limitations

The TPA will populate all non-COB loops (2320, 2330A, 2330B, 2430) with the data as it was received from the CCN Provider’s claim.

Beginning of Hierarchical Transaction:

BHT06 will contain the value ‘CH’

NM103 of the 1000A loop will contain the value ‘Name of Regional ‘VACCN TPA’ NM109 of the 1000A loop will contain the value ‘Regional VACCN ID’.

NM103 of the 1000B loop will contain the value ‘VHA Community Care Network’ NM109 of the 1000B loop will contain the value determined in conjunction with HCCH.

If SBR01 of the 2320 loop value is ‘P’ then SBR01 of the 2000B loop value must be ‘S’ SBR03 of the 2000B loop will contain the value associated for the given Region, for example:

Region 1 = ‘CCNNG1’ Region 2 = ‘CCNNG2’

NM109 of the 2010BA loop value is the Veteran’s ICN. The ICN format is 10 numeric, capital letter ‘V’, 6 numeric.

Ex: ‘9999999999V999999’

N403 of the 2010BA loop cannot be blank, must contain the subscriber Zip Code.

DMG01 of the 2010BA loop value is ‘D8’.

DMG02, subscriber date of birth, of the 2010BA loop value cannot be blank & cannot be greater than today’s date.

DMG03 of the 2010BA loop value must be ‘M’ or ‘F’.

If the Veteran’s Social Security Number (SSN) is available, then REF01 of the 2010BA loop value is ‘SY’ and the REF02 of the 2010BA value is the Veteran’s SSN.

NM109 of the 2010BB loop value will be determined in conjunction with the HCCH.

The CCN TPA will format the 837 with a single 2300 loop per each transaction (ST-SE).

CLM02 of the 2300 loop value is the Provider submitted Billed Amount.

If CLM05-01 of the 2300 loop value is ‘17’ or ‘20’ for Urgent Care then the Service Authorization Exception Code will be reported in the REF segment where REF01 = ‘4N’ as REF02 = ‘1’ in the 2300 loop.

If CLM05-01 of the 2300 loop value is ‘23’ for Emergency Care then the Service Authorization Exception Code will be reported in the REF segment where REF01 = ‘4N’ and REF02 = ‘3’ in the 2300 loop.

The Referral number will be reported in the REF02 where REF01 = ‘9F’ of the 2300 loop for all claims except Urgent Care episodes of care and flu shots.

The Precertification ID for claim level billing will be reported in the REF02 of the 2300 loop where REF01 = ‘G1’. The first two characters will always be PA.

The Contract ID will be reported in the CN104 where CN101 = ‘09’

The HCP segment in the 2300 loop will be populated with HCP01 = ‘10’, HCP02 with the allowed amount for the claim (this will equal the AMT*AU in the 2100 loop of the 835 sent to the provider for this claim), and the HCP04 with the CLIN for this episode of care.

The TPA will populate the 2320, 2330A, 2330B, and 2430 loops based on the requirements outlined in the TR3 front matter section 1.4.1 where the TPA is considered the Primary (SBR01 of 2320 loop = ‘P’) Payer and VA IVC is Secondary (SBR01 of 2000B loop = ‘S).

If the AMT02 is present where AMT01 = ‘D’ in the 2320 loop, then the DTP*573 will be populated at the 2430 loop or the 2330B loop. The DTP03 value where DTP01 = ‘573’ will be the same as the value in the BPR16 of the corresponding 835 sent from the TPA to the Community Care provider.

CCN TPA claims will always be paid by the TPA as primary, therefore claims adjudicated prior to being received by the TPA should be rejected. This means that the population of the 2320, 2330A, 2330B, and 2430 loops should not be populated for any other prior payers than the TPA.

The TPA ‘Payer Claim Control Number’ will be reported in the REF02 where REF01 = ‘F8’ of the 2330B loop. This value will be the same value reported by the TPA in the 835 sent to the Community Care Provider located in the CLP07 of the 2100 loop. Invoice submissions that are submitted for the first time will have a value ending in ‘0000’. Enumeration of the REF*F8 in Corrected or Resubmitted transactions outlined below.

The Precertification ID for individual services will be reported in the REF02 of the 2400 loop where REF01 = ‘G1’. The first two characters will always be PA.

Invoice submissions that are submitted for the first time will populate the REF02 where REF01 = ‘6R’ in the 2400 loop with a value ending in ‘0000’. Enumeration of the REF*6R in Corrected or Resubmitted transactions outlined below.

The HCP segment in the 2400 loop will be populated with HCP01 = ‘10’, HCP02 with the allowed amount for the service/procedure (this will equal the AMT*B6 in the 2110 loop of the 835 sent to the provider for this claim), and the HCP04 with the CLIN for this service/procedure.

Corrected or Resubmitted transactions:

The TPA will submit service lines in the same order as the originally submitted claim.

If CLM05-03 of the 2300 loop value is ‘7’ or ‘8’ then REF01 of the 2300 loop value will be ‘F8’ & REF02 of the 2300 loop will contain the value of the Previous Payers Claim Control Number

If CLM05-03 of the 2300 loop value is ‘7’ or ‘8’ then REF01 of the 2330B loop value will be ‘F8’ & REF02 of the 2330B loop will contain the value of the Current Payers Claim Control Number. It is expected that invoices that occur due to corrections and resubmissions will have unique Payer Claim Control numbers compared to the original claim submissions.

The TPA will not modify the frequency codes in corrected claims from what the provider submitted in the claim being reprocessed.

The TPA will increment the value in the REF02 where REF01 = ‘F8’ by 1 from the last submission.

The original submission ends in ‘0000’, the first resubmission ends in ‘0001’, the second resubmission ends in ‘0002’, etc.

The TPA will increment the value in the REF02 where REF01 = ‘6R’ by 1 from the last submission.

The original submission ends in ‘0000’, the first resubmission ends in ‘0001’, the second resubmission ends in ‘0002’, etc.

For each service line that is reprocessed two 2430 loops will be created. The first loop will be a reversal of the previous adjudication, and the second loop will be the current adjudication results.

REF01 of the 2300 where the value is ‘9F’ the REF02 of the 2300 loop value will be the VA Referral Number that is 12 characters always beginning with VA & ending in 10 digits.

Ex: ‘VA1234567890’

REF01 of the 2300 where the value is ‘G1’ the REF02 of the 2300 loop value will be the CCN TPA pre-authorization number with the first two characters always being PA.

8.0 Acknowledgements and/or Reports

8.1 999 Acknowledgements The VHA Integrated Veteran Care will return a 999 batch to the HCCH for each 837 Dental batch received from HCCH. The HCCH will route the 999s back to the appropriate CCN TPA from which the 837D was received.

9.0 Trading Partner Agreements

The Community Care Network Contracts are unlike previous contractual instruments awarded by VA in many ways. Payment for services provided under the CCN TPA contract is a reimbursement to the Contractor who is responsible for accurate and timely processing of claims. VA no longer re-adjudicates claims already processed by its Contractor(s) but enforces accuracy through a series of other checks and balances, including a third-party independent auditor. Because of the richness of information, standardized formats, and other determining factors, VA will receive invoices that model Payer to Payer EDI 837 COB transactions through a clearinghouse.

10.0 Transaction Specific Information

This section describes how ASC X12N Implementation Guides (IGs) adopted under HIPAA will be detailed with the use of a table. The tables contain a row for each segment that VHA has something additional, over and above, the information in the IGs. That information can:

1.Limit the repeat of loops, or segments.

2. Limit the length of a simple data element.

3. Specify a sub-set of the IGs internal code listings.

4. Clarify the use of loops, segments, composite and simple data elements.

5. Any other information tied directly to a loop, segment, composite, or simple data element pertinent to trading electronically with Acme Health Plan

In addition to the row for each segment, one or more additional rows are used to describe VHA usage for composite and simple data elements and for any other information.

The following table specifies the columns and suggested use of the rows for the detailed description of the transaction set companion guides.

Original Claim Submission:

Page # Loop ID Reference Name Codes Comments/ Notes

413 ISA Interchange Control Header

ISA01 - 00

ISA03 - 00

ISA05 - ZZ

ISA06

ISA07 - ZZ

ISA08

VACCNNG1

ISA11 - $

ISA13 - Unique Value

ISA14 - 1

ISA15 - P

ISA16 - :

ISA06 will contain a value determined in conjunction with HCCH & be 15 characters (including spaces) in length

ISA13 must be a positive unique number & identical to the IEA02

ISA15 must use 'T' in testing environment and ‘P’ in production environments

417 GS Functional Group Header

GS02

GS03 – VACCN

GS06 – Unique

ID

GS02 will contain the value found in the ISA06 GS06 will contain the value found in the GE02

66 BHT

Beginning of Hierarchical Transaction

BHT06 – CH

69 1000A NM1 Submitter Name

NM103 – VACCN

TPA

NM109

NM109 will contain the ‘Regional VACCN ID’

74 1000B NM1 Receiver Name

NM103 – VHA

Community Care Network

NM109

NM109 will contain a value determined in conjunction with

HCCH

111 2000B SBR Subscriber Information SBR01 - S

111 2000B SBR Subscriber Information

SBR03

SBR03 will contain the value associated for the given region, for example:

Region 1 = ‘CCCNN1’ Region 2 = ‘CCCNNG2’

114 2010BA NM1 Subscriber Name NM109 – Veteran’s ICN

ICN format is 10 numeric, capital letter ‘V’, 6 numeric Ex: ‘9999999999V999999’

118 2010BA N4 Subscriber City, State, Zip Code N403 Subscriber Zip Code cannot be blank

120 2010BA DMG

Subscriber Demographic Information

DMG01 – D8

DMG02

DMG03 – M or F

DMG02 cannot be blank & cannot be greater than today’s date DMG03 value must be ‘M’ or ‘F’

122 2010BA REF

Subscriber Secondary Identification

REF01 – SY

REF02 – Veteran Social Security Number (SSN)

If SSN is available

124 2010BB NM1 Payer Name NM109 NM109 will contain a value determined in conjunction with

HCCH

147 2300 CLM Claim Information CLM02 CLM02 will contain the billed amount from the Providers claim

165 2300 CN1 Contract Information

CN101 – 9

CN104 –

Contract ID

169 2300 REF

Service Authorization Exception Code

REF01 – 4N

REF02 – 1 or 3

Only use to indicate Urgent or Emergent Care:

REF02 = ‘1’ when CLM05-01 = ‘17’ or ‘20’ for Urgent Care

REF02 = ‘3’ when CLM05-01 = ‘23’ for Emergency Care

172 2300 REF Referral Number

REF01 – 9F

REF02 – VA

Referral Number

REF02

This will not be populated on Urgent Care or flu shots

174 2300 REF Prior Authorization

REF01 – G1

REF02

REF02 will be the CCN pre-authorization number with the first two characters always being ‘PA’

188 2300 HCP

Claim Pricing/Repricing Information

HCP01 – 10

HCP02

HCP04

HCP02 will contain the allowed amount for the claim (will be the AMT*AU in the 2100 loop of the corresponding 835 sent from the TPA to the Community Care provider)

HCP04 will contain the CLIN for this episode of care

224 2320 SBR Other Subscriber Information SBR01 - P

234 2320 AMT

Coordination of Benefits (COB) Payer Paid Amount

AMT01 – D

AMT02 –

Provider Paid Amount

AMT01 = ‘D’ is present, then AMT02 will be the amount the TPA paid to the Community Care provider in the CLP04 of the corresponding 835

254 2330B DTP Claim Check or Remittance Date

DTP01 – 573

DTP02 – D8

DTP03

When loop 2320 AMT = ‘D’ and loop 2430 DTP01 = ‘573’ is not used then Loop 2330B

DTP01 = ‘573’

DTP03 will contain the date found in the BPR16 of the corresponding 835 from the TPA to the Community Care provider

261 2330B REF

Other Payer Claim Control Number

REF01 – F8

REF02

For first time claim submissions only:

The REF02 will contain the TPA ‘Payer Claim Control Number’ that was reported by the TPA to the Community Care provider in the 835 2100 loop CLP07 with a value ending in ‘0000’

303 2400 REF Prior Authorization

REF01 – G1

REF02

REF02 value will be CCN Pre-authorization Number with the first two characters always being PA

305 2400 REF Line Item Control Number REF01 – 6R

For first time claim submissions only:

The REF02 will contain the TPA ‘Line Item Control Number’ that was reported by the TPA to the Community Care provider in the corresponding 835 2110 loop REF01 = ‘6R’ with a value ending in ‘0000’

314 2400 HCP

Line Pricing/Repricing Information

HCP01 - 10

HCP02

HCP04

HCP02 will contain the allowed amount for the service/procedure (will be the AMT*B6 in the 2110 loop of the corresponding 835 sent from the TPA to the Community Care provider)

HCP04 will contain the CLIN for this service/procedure

354 2430 DTP Line Check or Remittance Date

DTP01 – 573

DTP02 – D8

DTP03

When loop 2320 AMT = ‘D’ and loop 2330B DTP01 = ‘573’ is not used then Loop

2330B DTP01 = ‘573’

DTP03 will contain the date found in the BPR16 of the corresponding 835 from the TPA to the Community Care provider

Corrected or Resubmitted Claim Transaction:

Page # Loop ID Reference Name Codes Comments/ Notes

413 ISA Interchange Control Header

ISA01 - 00

ISA03 - 00

ISA05 - ZZ

ISA06 -

ISA07 - ZZ

ISA08

VACCNNG1

ISA11 - $

ISA13 - Unique Value

ISA14 - 1

ISA15 - P

ISA16 - :

ISA06 will contain a value determined in conjunction with HCCH & be 15 characters (including spaces) in length

ISA13 must be a positive unique number & identical to the IEA02

ISA15 must use 'T' in testing environment and ‘P’ in production environments

417 GS Functional Group Header

GS02

GS03 – VACCN

GS06 – Unique

ID

GS02 will contain the value found in the ISA06 GS06 will contain the value found in the GE02

66 BHT

Beginning of Hierarchical Transaction

BHT06 – CH

69 1000A NM1 Submitter Name

NM103 – VACCN

TPA

NM109

NM109 will contain the ‘Regional VACCN ID’

74 1000B NM1 Receiver Name

NM103 – VHA

Community Care Network

NM109

NM109 will contain a value determined in conjunction with

HCCH

111 2000B SBR Subscriber Information SBR01 - S

111 2000B SBR Subscriber Information

SBR03

SBR03 will contain the value associated for the given region, for example:

Region 1 = ‘CCCNN1’ Region 2 = ‘CCCNNG2’

114 2010BA NM1 Subscriber Name NM109 – Veteran’s ICN

ICN format is 10 numeric, capital letter ‘V’, 6 numeric Ex: ‘9999999999V999999’

118 2010BA N4 Subscriber City, State, Zip Code N403 Subscriber Zip Code cannot be blank

120 2010BA DMG

Subscriber Demographic Information

DMG01 – D8

DMG02

DMG03 – M or F

DMG02 cannot be blank & cannot be greater than today’s date DMG03 value must be ‘M’ or ‘F’

122 2010BA REF

Subscriber Secondary Identification

REF01 – SY

REF02 – Veteran Social Security Number (SSN)

If SSN is available

124 2010BB NM1 Payer Name NM109 NM109 will contain a value determined in conjunction with

HCCH

147 2300 CLM Claim Information CLM02 CLM02 will contain the billed amount from the Providers claim

165 2300 CN1 Contract Information

CN101 – 9

CN104 –

Contract ID

169 2300 REF

Service Authorization Exception Code

REF01 – 4N

REF02 – 1 or 3

Only use to indicate Urgent or Emergent Care:

REF02 = ‘1’ when CLM05-01 = ‘17’ or ‘20’ for Urgent Care

REF02 = ‘3’ when CLM05-01 = ‘23’ for Emergency Care

172 2300 REF Referral Number

REF01 – 9F

REF02 – VA

Referral Number

REF02

This will not be populated on Urgent Care or flu shots

171 2300 REF Payer Claim Control Number

REF01 – F8

REF02

Only for Corrected or Resubmitted transactions:

When loop 2300 CLM05-

03 = ‘7’ or ‘8’, REF02 will contain the value of the Previous Payers Claim Control Number. The TPA will increment the value in the REF02 where REF01 = ‘F8’ by 1 from the last submission. The original submission ends in ‘0000’, the first resubmission ends in ‘0001’, the second resubmission ends in ‘0002’, etc.

174 2300 REF Prior Authorization

REF01 – G1

REF02

REF02 will be the CCN pre-authorization number with the first two characters always being ‘PA’

188 2300 HCP

Claim Pricing/Repricing Information

HCP01 – 10

HCP02

HCP04

HCP02 will contain the allowed amount for the claim (will be the AMT*AU in the 2100 loop of the corresponding 835 sent from the TPA to the Community Care provider)

HCP04 will contain the CLIN for this episode of care

224 2320 SBR Other Subscriber Information SBR01 - P

234 2320 AMT

Coordination of Benefits (COB) Payer Paid Amount

AMT01 – D

AMT02 –

Provider Paid Amount

MT01 = ‘D’ is present, then AMT02 will be the amount the TPA paid to the Community Care provider in the CLP04 of the corresponding 835

254 2330B DTP Claim Check or Remittance Date

DTP01 – 573

DTP02 – D8

DTP03

When loop 2320 AMT = ‘D’ and loop 2430 DTP01 = ‘573’ is not used then Loop 2330B

DTP01 = ‘573’

DTP03 will contain the date found in the BPR16 of the corresponding 835 from the TPA to the Community Care provider

257 2330B REF

Other Payer Prior Authorization Number

REF01 – G1

REF02

REF02 value will be CCN Pre-authorization Number with the first two characters always being PA

261 2330B REF

Other Payer Claim Control Number

REF01 – F8

REF02

For corrected or resubmitted claim submissions only:

The REF02 will contain the Current Payers Claim Control Number that was reported by the TPA to the Community Care provider in the 835 2100 loop CLP07. The TPA will increment the value in the REF02 where REF01 = ‘F8’ by 1 from the last submission.

The original submission ends in ‘0000’, the first resubmission ends in ‘0001’, the second resubmission ends in ‘0002’, etc.

303 2400 REF Prior Authorization

REF01 – G1

REF02

REF02 value will be CCN Pre-authorization Number with the first two characters always being PA

305 2400 REF Line Item Control Number REF01 – 6R

For corrected or resubmitted claim submissions only:

The REF02 will contain the TPA ‘Line Item Control Number’ that was reported by the TPA to the Community Care provider in the corresponding 835 2110 loop REF01 = ‘6R’. The TPA will increment the value in the REF02 where REF01 = ‘6R’ by 1 from the last submission.

The original submission ends in ‘0000’, the first resubmission ends in ‘0001’, the second resubmission ends in ‘0002’, etc.

314 2400 HCP

Line Pricing/Repricing Information

HCP01 - 10

HCP02

HCP04

HCP02 will contain the allowed amount for the service/procedure (will be the AMT*B6 in the 2110 loop of the corresponding 835 sent from the TPA to the Community Care provider)

HCP04 will contain the CLIN for this service/procedure

354 2430 DTP Line Check or Remittance Date

DTP01 – 573

DTP02 – D8

DTP03

When loop 2320 AMT = ‘D’ and loop 2330B DTP01 = ‘573’ is not used then Loop

2330B DTP01 = ‘573’

DTP03 will contain the date found in the BPR16 of the corresponding 835 from the TPA to the Community Care provider

11.0 Approval Signatures

This section is used to record the approval of the Payer EDI Companion Guide during the Formal Review. Conduct the review face-to-face where signatures can be obtained ‘live’ during the review. If unable to conduct a face-to-face meeting, conduct the review via a teleconferencing medium and capture concurrence during the meeting or if approved by all parties, through email. The Scribe should add names by each position cited.

The following members governing the document are required to sign. Please annotate signature blocks accordingly.

X__________________