Attachment If Post-Adjudication 835 Community Care Network Companion Guide.pdf

PRE-DECISIONAL

DEPARTMENT OF VETERANS AFFAIRS INTEGRATED

VETERAN CARE (IVC)

HIPAA Transaction - Standard Companion Guide Health Care Claim Payment Advice

Based on ASC X12 version 005010x221A1 (835 Electronic Remittance Advice)

Community Care Network 005010x221A1

Remittance Advice from Third Pary Administrator to Community Care Provider

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 Post- Adjudication Claim Payment/Advice (835) to support the Integrated Veteran Care (IVC) Community Care Network (CCN). Post-Adjudication refers to those claims that the Community Care Network Third-Party Administrator (CCN TPA) adjudicates for reimbursement and remittance advice that are submitted by Community Care Providers.

The VA IVC follows the ASC X12N/005010X221A1, Health Care Claim Payment/Advice 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 Institutional TR3 when processing ASC X12N/005010X221A1, Health Care Claim Payment/Advice 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- CCN Provider

Step 1. The CCN TPA will adjudicate claims submitted by CCN Providers that have passed syntax and business rule validation.

Step 2. The CCN TPA will reimburse CCN Provider claims on payment instruments (whether check or EFT) separate from any other contract or program (paying just the claims under the CCN Regional Payer ID). This will allow the 835 transactions to be created with only CCN patients, which in turn allows the transactions to be sent to IVC without HIPAA violations.

Step 3. The CCN TPA will deny CCN Provider claims on separate 835 transactions from any other contract or program (denying just the claims under the CCN Regional Payer ID). This will allow the 835 transactions to be created with only CCN patients, which in turn allows the transactions to be sent to IVC without HIPAA violations.

Step 4. The CCN TPA will batch CCN 835s into a batch that will exclude any other transactions of any other Payer ID.

Step 5. The CCN TPA will transmit the CCN 835 batch to the TPA HCCH.

Step 6. TPA HCCH will transmit copy of X12 835 to IVC HCCH.

1.3 References

The 837I 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

2.0 Getting Started

2.1 Working with VA IVC Health Care Programs

All certification and testing of a new trading partnership must be coordinated with the IVC 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 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/

4.0 Connectivity with the Payer/ Communications

Process Flows

VA Parallel with HCCH as source of all transactions to VA

T P A

H C

C H

C C

N P ro v id e r

T P A

V A

V A

H C

C 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 Post-Adjudication 835 batches sent from the CCN TPA to the TPA

HCCH will be decided between the TPA HCCH and the CCN TPA. The CCN TPA will need to provide documentation on the Sender and Receiver IDs to the HCCH representing IVC and the Payer EDI team. An example of that documentation in found in 6.3.

6.2 GS-GE

The GS and GE values for the Post-Adjudication 835 batches sent from the CCN TPA to the TPA

HCCH will be decided between the TPA HCCH and the CCN TPA. The CCN TPA will need to provide documentation on the Sender and Receiver IDs to the HCCH representing IVC and the Payer EDI team. An example of that documentation in found in 6.3.

6.3 835 Envelope Format

EDI 835

File Type: 835

Data Element Separator Delimiter:

Repetition Separator: ̂

Component Element Delimiter: :

Segment Terminator Delimiter: ~

ISA01 value: 0

ISA02 value: 10 spaces

ISA03 value: 0

ISA04 value: 10 spaces

ISA05 value: ZZ

ISA06 value: VACCN

ISA07 value: ZZ

ISA08 value: TPA HCCH ID

ISA09 value: yymmdd

ISA10 value: hhmm

ISA11 value: $

ISA12 value: 00501

ISA13 value: must match IEA02 Unique ID

ISA14 value: 0

ISA15 value: P

ISA16 value: :

GS01 value: HP

GS02 value: must match ISA06 VACCN

GS03 value: must match ISA08 TPA HCCH ID

GS04 value: ccyymmdd

GS05 value: hhmm

GS06 value: Unique ID

GS07 value: X

GS08 value: 005010X221A1

2100A NM103: VHA Community Care Network

2100A NM109: CCN Payer ID

2100B NM103: VACCN

2100B NM109: VACCN NG1

7.0 Payer Specific Business Rules and Limitations

The CCN TPA will follow all CAQH CORE rules on CARC/RARC combinations.

The CCN TPA will restrict reimbursements to include only CCN claims. No claims for other Payer IDs will be included with payments for CCN into a single payment instruments (whether check or EFT).

This will allow the 835 transactions to be created with only CCN patients, which in turn allows the transactions to be sent to IVC without HIPAA violations.

The CCN TPA will populate the REF*2U of the 1000A loop with the Payer ID for the specific CCN Region.

The CCN TPA will restrict denied CCN claims to be in separate 835 transactions from any other contract or program (denying just the claims under the CCN Regional Payer ID). This will allow the 835 transactions to be created with only CCN patients, which in turn allows the transactions to be sent to IVC without HIPAA violations.

The CCN TPA can report paid claims (2100 loop) and denied claims (2100 loop) in the same 835 transaction as long as non-CCN claims are excluded.

The CLP07 will be the value sent in the 277CA REF*1K for claim being reported in the 2100 loop when CLP02 <> ‘22’.

The CCN TPA will populate the REF*BB if the CCN TPA assigns a Referral number in the adjudication of a claim.

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 835 batch received from HCCH. The HCCH will route the 999s back to the appropriate CCN from which the 835 was received.

9.0 Trading Partner Agreements

All trading partner agreements are to be coordinated through the IVC Payer EDI Team.

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.

Post Adjudication 835:

Page # Loop

ID

Reference Name Codes Length Comments/ Notes

559 ISA

Interchange Control Header

ISA01 - 00

ISA03 - 00

ISA05 - ZZ

ISA06

ISA07 - ZZ

ISA08

VACCNNG1

ISA11 - $

ISA13 - Unique Value

ISA14 - 0

ISA15 - P

ISA16 - :

563 GS

Functional Group Header

GS02

GS03 – VACCN

GS06 – Unique

ID

92 1000A REF

Additional Payer Identification

REF02 – Payer

ID

REF02 will contain the Regional unique Payer ID such at ‘VACCN NG1’

123 2100 CLP

Claim Payment Information

CLP01 <> ‘2’,

or ‘3’

CLP07 – Payer Claim Control Number

CCN will always pay as primary, CLP01 cannot report paying as secondary or tertiary

Payer Claim Control Number will equal the value in the REF*1K of the corresponding 277CA

169 2100 REF

Other Claim Related Identification

REF01 = ‘BB”

REF02 – VA

Referral Number

Referral Number will be returned if Referral was used in adjudication and was not reported on the claim.

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__________________