PacifiCare Electronic Data Interchange

837 Transaction Companion Guide

Health Care Claim:

Professional
(Version 2.0 – August 2003)

837 – Part I

ANSI ASC X12N 837 (00401X098 & 004010X098A1)

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Table of Contents

INTRODUCTION .......................................................................................................................... 4

ASSUMPTIONS ........................................................................................................................... 5

PREFERENCES AND CONVENTIONS....................................................................................... 5

General File Submission Requirements .............................................................................................................. 6
Causes for Rejection ............................................................................................................................................. 8
Field Lengths and Values ..................................................................................................................................... 8

COMMUNICATION METHODS SUPPORTED ............................................................................ 9

Clearinghouse ........................................................................................................................................................ 9
Direct Submission.................................................................................................................................................. 9

TRANSACTION STRUCTURE AND PROCESSING................................................................. 10

Structure of Transaction: At the ST-SE Loop.................................................................................................. 10
Batch Mode Processing....................................................................................................................................... 10
Transaction Processing – Within PacifiCare's Processing System ................................................................. 10
Privacy and Security Protection ........................................................................................................................ 10

ENCRYPTION REQUIREMENTS .............................................................................................. 11

HANDLING ACKNOWLEDGEMENTS ...................................................................................... 11

ANSI ASC X12 ACKNOWLEDGEMENTS..................................................................................................... 11
TA1 Interchange Acknowledgment .................................................................... Error! Bookmark not defined.
997 Functional Acknowledgment .................................................................................................................. 11

HANDLING ERRORS ................................................................................................................ 11

Content Errors and Back-end Errors ............................................................................................................... 11

//HIPAA/DSR/Comp Guides/837 2 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

997 Functional Acknowledgement Transaction ............................................................................................... 11

APPENDIX A – SAMPLE FILES................................................................................................ 14

Figure 1 – Original Inbound File ....................................................................................................................... 14
Figure 2 – Original Inbound File – Summarized Version ............................................................................... 15
Figure 3 – 997 Acknowledgment to Original Inbound File ............................................................................. 15
Figure 4 – 997 Acknowledgment to Original Inbound File – Summarized Version ..................................... 16
TA1 Interchange Acknowledgement Transaction................................................. Error! Bookmark not defined.
Figure 5 – TA1 Acknowledgment to Original Inbound File.............................. Error! Bookmark not defined.
Examples of Errors ............................................................................................................................................. 18

APPENDIX B – TESTING REQUIREMENTS ............................................................................ 20

COMBINED 837 PROFESSIONAL TRANSACTION SET – 004010X098 & 004010X098A1ERROR! BOOKMARK NOT DEFINED.

//HIPAA/DSR/Comp Guides/837 3 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Introduction
PacifiCare is publishing this Electronic Data Interchange (EDI) 837 Professional Transaction Companion Guide (Companion Guide) to accompany
the ASC X12N Combined Professional Implementation Guide (Implementation Guide) for the ASC X12N Health Care Claims Professional (837)
Transaction Set. (Note: Both the 837 Professional Transaction Companion Guide and the ASC X12N Combined Professional Implementation Guide
include both the 004010X098 and 004010X098A1 transaction sets.)
The primary purpose of this Companion Guide (Companion Guide) is to minimize the variability in the transaction set that is exchanged within all of
the regions of PacifiCare. The Companion Guide will document assumptions, conventions and preferences that PacifiCare expects health plans,
providers, and information system vendors to comply with.
Additionally, the Companion Guide will help to walk organizations through the implementation process so that the resulting transaction will meet the
following business objectives:
1. Convey all required business information: The transaction will convey the comprehensive set of information that is required for health plans
to conduct their business.
2. Interpret information in the same way: The definition of the transaction will be specific so that Trading Partners can correctly interpret the
information that is received from each other from a business perspective.
3. Simplify the communication: The transaction will be standard to simplify communication between Trading Partners as well as to comply with
the Health Insurance Portability and Accountability Act (HIPAA) regulations.
The underlying premise of the PacifiCare Companion Guide is that it defines the superset of business functionality for the ASC X12N Health Care
Claims Professional (837) Transaction Set. The Implementation Guide provides general information about EDI transmission, such as delimiters,
enveloping, and related topics. PacifiCare’s Companion Guide will not duplicate these efforts.
In order to establish a simplified implementation environment, the Companion Guide describes a set of assumptions and conventions that will be
followed by Trading Partners as they implement the 837 transaction and interpret the information that is contained within it. These conventions
provide additional clarity about data structures and the data elements (i.e., what they mean) and describe how these data elements relate to
information contained in the information systems belonging to each Trading Partner (i.e., how they will be used).
It should be noted that the Companion Guide does not add, delete or change the name of any data element or segment, nor does the Companion Guide
change the meaning or intent of any implementation specification, that is specified in the Implementation Guide. HIPAA Implementation Guides are
available through Washington Publishing, Inc. at:
http://www.wpc-edi.com/

//HIPAA/DSR/Comp Guides/837 4 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Assumptions
The following assumptions are being made for purposes of this guide:
• The Interchange Transmission refers to an ISA/IEA.
• The Functional Group refers to the GS/GE.
• The Transaction Set refers to the ST/SE (can come in multiple functional groups).
• Providers or clearinghouses submitting the 837 Health Care Claim transaction directly to PacifiCare must first be registered. Registration
includes the exchange of important information necessary for successful e-Commerce, including submitter and receiver information,
connectivity specifications, etc. For most questions relating to information in this guide, contact the PacifiCare Enterprise EDI Services
(EES) department at:
Email: EDISupport@phs.com
Fax: 714-226-4046 Attn: EDI Support
Telephone: 1-800-203-7729∗
• Health Care Claim transactions submitted to PacifiCare, either directly or through a clearinghouse, must be compliant with HIPAA.
According to HIPAA legislation, a penalty of not more than $100 for each violation, and up to $25,000 may be imposed by the U.S.
Department of Health and Human Services for transactions that are not compliant. For more information, please see the U.S. Department of
Health and Human Services website at:
http://aspe.os.dhhs.gov/admnsimp/pl104191.htm#261

• 837 Health Care Claims transactions submitted to PacifiCare are assumed to be production-ready. The provider, clearinghouse, and system
vendor(s) will have completed testing prior to submission to ensure HIPAA compliance.

Preferences and Conventions

The items listed below outline specific preferences and conventions to be used when transmitting data to PacifiCare.

∗
For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative.

//HIPAA/DSR/Comp Guides/837 5 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

General File Submission Requirements

1. Trading Partner Agreements specify the terms and conditions by which transactions are exchanged electronically with PacifiCare. This
Companion Guide may be an addendum to a new or existing Trading Partner Agreement or other Business Agreement.
2. PacifiCare strongly recommends that every Trading Partner submitting the 837 Health Care Claim transaction directly to PacifiCare sign a
Trading Partner Agreement.
3. It is recommended in the Implementation Guide that each transaction be limited to a maximum of 5000 claims.
4. PacifiCare requests that providers obtain certification from an approved Third-Party Certification System and Service (TPCSS), stipulating that its
transactions are HIPAA compliant. For more information about certification and certification vendors, speak to the EES Project Manager.
5. While PacifiCare supports all of the characters in the extended character set, it is recommended that incoming 837 claim data use the basic
character set as defined in Appendix A of the Implementation Guide.
6. The subscriber hierarchical level (HL segment) must be in order from one, in increments of one (+1), and must be numeric.
7. A carriage return/linefeed combination can be used if mutually agreed upon between the submitter and PacifiCare.
8. Segments and data elements labeled as “Not Required by PacifiCare” in this Companion Guide, but labeled as “Situational” in the
Implementation Guide, may still be accepted and validated to ensure HIPAA compliance. However, PacifiCare will not actually process these
segments and data elements.
9. PacifiCare will receive the following data element decimal format stated below:
• Loop 2300 – QTY02 – Claim Days Count – Will receive in whole numbers but will be truncated if received in decimal format.
• Loop 2400 – SV205 – Service Unit Count:
If SV103 = UN – Agreed to accept 1st decimal digit, additional information will be dropped.
If SV103 = MJ – Will be truncated.
If SV103 = F2 – Will be truncated.
• Loop 2400 – CR102, CR106, CR201, CR202, CR206, CR207, CR303, CR502 – Will be truncated.
• Loop 2430 – SDV02 – Service Line Paid Amount – Dollar Amount with 2 digits after decimal.
SVD05 – Paid Service Unit Count – Will be truncated.
10. Data submitted to PacifiCare in ANSI HIPAA standard format may be translated into a proprietary format for purposes of internal processing.
Because of this, some of the data submitted may not be used in the adjudication process.

//HIPAA/DSR/Comp Guides/837 6 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

11. PacifiCare suggests retrieval of the ANSI 997 functional acknowledgment files on or before the first business day after the claim file is submitted,
but no later than five business days after the file submission. Beginning with the fifth business day after submission, it will no longer be
available.
12. Encryption and compression of files using PGP v2.6 or later is supported for transmissions between the submitter and PacifiCare.
13. PacifiCare prefers to receive only one transaction type (records group) per interchange (transmission). A submitter should only submit one GS-
GE (Functional Group) within an ISA-IEA (Interchange).
14. Trading Partners cannot send test and production information within the same transaction file, regardless of the transaction. Test data and
production data must be submitted in separate files. Notify your EES Project Manager if you intend to send test data.
15. The Implementation Guide allows the following scenarios per transaction:
• Multiple patients per subscriber.
• A claim under the subscriber and a claim under each one of the patients for that same subscriber.
• Multiple claims under the subscriber and multiple claims under each one of the patients for that subscriber.
• A combination of all of the above.
This complex nesting can be accepted into PacifiCare’s system. However, PacifiCare recommends the following, more simplistic approach, to
generating a claims transaction:
Subscriber #1
Patient #1
Claim#1
Subscriber #1
Patient #1
Claim#2
Subscriber #1
Patient #2
Claim#1
Etc….

//HIPAA/DSR/Comp Guides/837 7 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

While there is some redundancy using this method, there is less chance for errors to occur thereby, allowing the claims to be processed more
expeditiously.
Note: If one claim in the ST-SE transaction set is found to be in error, then all claims within the ST-SE set are rejected.
16. As of the release of this document (August 2003), PacifiCare accepts the following versions of the Implementation Guide, and any future versions
as specified by the regulation:
• Professional ANSI ASC X12N 837 (004010X098 & 004010X098A1)
17. Only multiple data loops or segments should be populated with the first occurrence, and each loop or segment populated consecutively thereafter.
There should be no loops or segments without data.

Causes for Rejection

1. Delimiters must be consistently applied throughout the transmissions. Any delimiter can be used as long as the same one is used throughout the
transmission. Printable characters are preferred.
2. Using a dash (-) in the submitter ID will cause an interchange/transmission to be rejected as an error.
3. Only loops, segments, and data elements valid for the Implementation Guide will be translated. Submission of data that is not valid based on the
Implementation Guide will cause transaction sets to be rejected.
4. If a segment or data element within a segment is specified in the Implementation Guide as “Not Used,” yet is present in the transaction set, it will
be rejected as an error.
5. PacifiCare will reject an interchange transmission that is submitted with an invalid value in either ISA08 (Receiver ID) and/or GS03 (Application
Receiver’s Code) based on the Trading Partner Set Up Form.
6. PacifiCare will reject an interchange transmission that is not submitted with unique values in either the ST02 (Transaction Set Control Number)
or GSO6 (Group Control Number) elements within the interchange transmission.
Field Lengths and Values
1. Credit Card and Debit Card information will not be considered for processing (2300 loop, AMT01=MA and 2010BD loop).
2. Valid values for CLM05-3 (Claim Frequency Type Code) are “1” (Original) and “7” (Replacement). However, claims with a value of “7” will
be processed as Original claims and will result in duplicate claim rejection because PacifiCare’s claims processing system does not process
electronic replacements.

//HIPAA/DSR/Comp Guides/837 8 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

3. The maximum dollar amount that can be submitted for professional claims is $99,999.99. If any dollar amount field is in excess of $99,999.99,
that transaction will not be considered for processing.
4. The number of characters that will be supported for CLM01 (Claim Submitter Identifier) is less than or equal to 17 for Professional Claims and
less than or equal to 20 for Institutional Claims.
5. CUR02 (Currency Code) Currency codes other than “USA” will not be considered during processing.
6. While “ZZ” options are accepted, they are not utilized in PHS systems unless expressly noted in this Companion Guide. One notable exception is
that the Professional Encounters System will post the rendering provider taxonomy code.
7. SV104 (Service Unit Counts – units or minutes) cannot be in excess of 999.9. If this field is in excess of 999.9, the transaction will not be
considered for processing.
8. BHT02 (Transaction Set Purpose Code) Values other than “00” will not be considered during processing.

Communication Methods Supported

PacifiCare supports the following communication methods:

Clearinghouse
For clearinghouse EDI claims submission, it is necessary to contact the clearinghouse directly. They will provide all of the necessary testing and
submission information required.

Direct Submission
For direct submission of eligibility requests to PacifiCare or for details regarding communication protocols, contact the PacifiCare EES department
at:
Email: EDISupport@phs.com
Fax: 714-226-4046 Attn: EDI Support
Telephone: 1-800-203-7729∗

∗
For technical assistance on new or existing electronic transmissions. For all other questions, contact the appropriate PacifiCare representative.

//HIPAA/DSR/Comp Guides/837 9 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Transaction Structure and Processing

PacifiCare will utilize a separate ISA-IEA set for each different type of transaction. If, for example, an electronic transmission between two trading
partners contains claims (HIPAA 837 transaction set) and referrals (HIPAA 278 transaction set), the submitter should send two ISA-IEA sets: one for
claims (837) and one for referrals (278).

Structure of Transaction: At the ST-SE Loop

All information between an ST and the corresponding SE will relate to claims from one billing provider. There can be multiple pay-to providers,
multiple subscribers, multiple patients and multiple claims within the ST-SE set as long as they are all for the same billing provider.

Batch Mode Processing

The 837 transaction will be implemented in batch mode. The submitting organization will send the 837 transaction to the Health Plan through some
means of telecommunications and will not remain connected while the Health Plan processes the transaction.
Re-transmitted files received with the same ISA envelope data will be rejected and a 997 acknowledgement will be sent.

Transaction Processing – Within PacifiCare's Processing System

PacifiCare’s production system will process the data contained in an 837 transaction in one of three ways:
• Process It: PacifiCare will process information that is compliant with the HIPAA standard and is consistent with PacifiCare’s practices. The
data elements within the transaction will be reviewed for further processing. Information related to the status of the payable claim transaction
can be accessed by utilizing the HIPAA 276/277 inquiry/response. The status of professional encounters cannot be ascertained via 276/277
inquiry/response.
• Forward It: If the claim is the responsibility of a capitated entity, claim information will be forwarded to the responsible medical group or
IPA.
• Reject It: PacifiCare will reject information that is not compliant with the HIPAA standard. One example would be a transaction that is
missing required data elements. The transaction will be rejected and the submitter notified via a 997 acknowledgement.

Privacy and Security Protection

PacifiCare will comply with the privacy and confidentiality requirements as outlined in the HIPAA Privacy and Security regulations regarding the
need to protect health information. All Trading Partners are also expected to comply with these regulations.

//HIPAA/DSR/Comp Guides/837 10 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Encryption Requirements
PacifiCare will comply with the data encryption policy as outlined in the HIPAA Privacy and Security regulations regarding the need to encrypt
health information and other confidential data. All data within a transaction that is included in the HIPAA definition of Electronic Protected Health
Information (ePHI) will be subject to the HIPAA Privacy and Security regulations and PacifiCare will adhere to such regulations and the associated
encryption rules. All Trading Partners are also expected to comply with these regulations and encryption policies.

Handling Acknowledgements

ANSI ASC X12 ACKNOWLEDGEMENTS

• PacifiCare utilizes the 997 Acknowledgement.
997 Functional Acknowledgment
The 997 Functional Acknowledgement will be sent back to the Trading Partner as determined by Trading Partner setup to indicate the success or
failure of 837 compliance validation within each GS/GE segment.
PacifiCare will return 004010 as the version in GS08 (Version/Release/Industry Identifier Code) of the 997.
For an example of the TA1 Interchange Acknowledgment and the 997 Functional Acknowledgement, refer to the Handling Errors section in this
document. Should further details on either transaction be required, refer to the Implementation Guide, Appendix B.

Handling Errors

Content Errors and Back-end Errors

All content and back-end related errors that may exist in a HIPAA transaction will be handled and addressed by PacifiCare in the same way they are
currently being handled. For additional information, contact the PacifiCare EES department.

997 Functional Acknowledgement Transaction

Refer to Figures 1 thru 4 on the following pages which contain an actual 997 Functional Acknowledgement transaction.
Figure 1 is the original inbound file. Figure 2 is a summarized version of the original inbound file and shows only the information needed to create
the associated 997 acknowledgment for this example.

//HIPAA/DSR/Comp Guides/837 11 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

The inbound file contains a single interchange envelope, ISAControl=(ISA13=000000900). Within the interchange envelope is a single functional
group, GSControl#(GS06=1). This functional group contains two transaction sets, ST Control#(AK202=0021) and ST Control#(AK202=0022).
Each transaction set contains a single claim. A transaction set could contain multiple claims; however, for purposes of this example, only one claim
is included.
A 997 acknowledges functional groups and transaction sets within the functional group. Within the file, an error with transaction set ST
Control#(AK202=0021) has been included. There are no errors with transaction set ST Control#(AK202=0022). The transaction set Control#
(AK202=0021) contains a HIPAA syntax error (invalid code) with the BHT06 data element. (Refer to the shaded portions of the examples to trace
the error through the process.)

//HIPAA/DSR/Comp Guides/837 12 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

The corresponding 997 acknowledgment in Figure 3 contains elements populated from data from the original inbound file, as well as elements
generated as a result of PacifiCare processing. (Note: Figure 4 is a summarized version of the acknowledgment file and only shows the
information necessary to create the associated 997 acknowledgment for this example.)
PacifiCare now becomes the sender at the interchange level, and the original interchange submitter becomes the receiver. PacifiCare now creates its
own interchange control number, ISAControl=(ISA13=000000005). The functional group contains only functional acknowledgments. PacifiCare
now creates its own functional group control number, GSControl#(GS06=5).
The transaction set contains multiple acknowledgments. PacifiCare creates its own transaction set control number, STControl#(ST02=0005). Each
AK1/AK9 envelope is the acknowledgment of a single functional group. GS Control#(AK102=1) indicates which functional group is being
acknowledged. (AK901=P, Partially Accepted) indicates the functional group result of the syntax validation. “Partially Accepted” means that
some transaction sets within the functional group were accepted and passed through the back-end system for processing, and some were rejected.
The ACK2/AK5 envelope is the acknowledgment of a single transaction set. The ST Control#(AK202=0021) acknowledgment shows the error to
be within the AK3/AK4 segments. AK3 locates the segment where the error is occurring. AK4 locates and describes the element within the segment
in error. In the case of multiple errors within the same transaction set, the AK/AK4 combination will repeat.
ST Control#(AK202=0022) acknowledgment shows a positive acknowledgment of a transaction set.

//HIPAA/DSR/Comp Guides/837 13 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Appendix A – Sample Files

Figure 1 – Original Inbound File

1: ISA*00* *00* *ZZ*SUBMITTERS ID *ZZ*RECEIVERS ID

*010412*1253*U*00401*000000900*1*T*:~
2: GS*HC*SenderID*ReceiverID*20010412*1310*1*X*004010X098~
3: ST*837*0021~
4: BHT*0019*00*0123*20010412*1023*NV~
5: REF*87*004010X098D~
6: NM1*41*2*JAMES A SMITH, M.D.*****46*TGJ23~
7: PER*IC*LINDA*TE*8015552222*EX*231~
8: NM1*40*2*ABC CLEARINGHOUSE*****46*66783JJT~
9: HL*1**20*1~
10: NM1*85*2*Lantana and Associates*****24*587654321~
11: N3*1234 Sonic Way St~
12: N4*Jacksonville*FL*33111~
13: HL*2*1*22*0~
14: SBR*P*18*******CI~
15: NM1*IL*1*SMITH*TED****MI*000221111A~
16: N3*236 N MAIN ST~
17: N4*MIAMI*FL*33413~
18: DMG*D8*19430501*M~
19: NM1*PR*2*BLUE CROSS BLUE SHIELD OF NORTH DAK*****PI*741234~
20: N2*OTA~
21: CLM*26462967*540***21::1*Y*A*Y*Y*C~
22: DTP*431*D8*19981003~
23: DTP*435*D8*20010401~
24: REF*D9*17312345600006351~
25: HI*BK:0340*BF:V7389~
26: NM1*82*1*SMITH*ANDREW****24*788893334~
27: PRV*PE*ZZ*203BA0300Y~
28: NM1*FA*2*GENERAL HOSPITAL*****24*456123780~
29: N3*345 MAIN STREET~
//HIPAA/DSR/Comp Guides/837 14 08/29/03
30: N4*MIAMI*FL*33199~
31: LX*1~
 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Figure 2 – Original Inbound File –

Summarized Version

ISA Sender(ISA06=SUBMITTERS ID), Receiver(ISA07= RECEIVERS ID),

ISAControl=(ISA13=000000900)
Figure 3 – 997 Acknowledgment to
GS– GS01=(HC, Health Care Claim 837), GS02=(SenderID), GS03=(ReceiverID),
Original Inbound File
GSControl#(GS06=1),GS08=(004010X098)
1: ISA*00* *00* *ZZ*REC
*020403*1836*:*00403*000000005*0*P*>~
ST – 837 Professional Claims, STControl# (ST02=0021), claim/encounter(BHT06=CH), trans
type(REF02=(004010X98D) 2: GS*FA*ReceiverID*SenderID*200204

SE – 837 Professional Claims,.SEControl# (SE02=0021), SegCount(SE01=33), 3: ST*997*0005~

…
ST – 837 Professional Claims, STControl# (ST02=0022), claim/encounter(BHT06=RP), trans 4: AK1*HC*1~
type(REF02=(004010X98)
SE – 837 Professional Claims,.SEControl# (SE02=0022), SegCount(SE01=32) 5: AK2*837*0021~
6: AK3*BHT*2**8~
7: AK4*6*640*7*NV
8: AK5*R~
//HIPAA/DSR/Comp Guides/837 15 08/29/03
9: AK2*837*0022~
10: AK5*A~
 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Figure 4 – 997 Acknowledgment to Original Inbound File – Summarized Version

ISA Sender(ISA06= RECEIVERS ID), Receiver(ISA07= SUBMITTERS ID),

ISAControl=(ISA13=000000005)
GS– GS01=(FA, Functional Acknowledgment 997), GS02=( ReceiverID), GS03=( SenderID),
GSControl#(GS06=5),GS08=(004030)
ST – 997 Functional Acknowledgment, STControl# (ST02=0005)

AK1 = Acknowledging Functional Group (AK101=HC), GS Control#(AK102=1)

AK2 = Acknowledging Transaction Set Cons(AK201=837), ST

Control#(AK202=0021)
AK3 = Data Segment in Error, tag(AK301=BHT), Segment pos
from Start(AK302=2)
AK4 = Data Element in Error, position(AK401=6), Error
Code(AK403=7, Invalid Code Value), Bad Value(AK404=NV)
AK5 = Transaction Set Response(AK501=R, rejected)

AK2 = Acknowledging Transaction Set Cons(AK201=837), ST

Control#(AK202=0022)
AK5 = Transaction Set Response(AK501=A, accepted)

AK9 = Functional Group Response(AK901=P, Partially Accepted),

TransSetIncluded(AK902=2),

//HIPAA/DSR/Comp Guides/837 16 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

 Receipt of a TA1 or 997 acknowledgement does not indicate the success or failure of processing into PacifiCare’s claims processing
adjudication system.

//HIPAA/DSR/Comp Guides/837 17 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Examples of Errors
The following are some of the conditions that could cause errors to occur at the various levels.
ISA/ISE
Level 1
ISA*00* *00* *ZZ*133052274 *ZZ*959590001 *011022*1253*U*00401*000000905*1*T*:~
Error for ISA06 (D.E. I06) at col. 36 (AN 15/15) "133052274 ": Value too short
Level 2
ISA*00* *00* *40*133052274 *ZZ*959590001 *011022*1253*U*00401*000000905*1*T*:~
Code Value "40" not found for ISA05 (D.E. I05) at col. 33

GS/GE
Level 1
(1) GS*HC*133052274*959590001*20011022*1310*1*X~
No EDI Standard specified in envelope header
h Should have looked like:
GS*HC*133052274*959590001*20011022*1310*2*X*004010X098~

(2) GS*HC*133052274*959590001*20011022*1310*2*X*004010X098~
GE*1*1~
¾ End of Functional Group, Ctl. No. 2, contains 1 Transaction Set(s)
Functional Group Ctl No. 1 in GE doesn't match GS
Level 2

//HIPAA/DSR/Comp Guides/837 18 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

GS*HC*133052274*959590001*20011022*1310*1*Y*004010X098
Code Value "Y" not found for GS07 (D.E. 455) at col. 43

ST/SE
Level 1
(1) ( ST*837*0021**~
Excess Trailing Data Element Delimiter(s) after ST02 (D.E. 329) at col. 8

(2) ST*837*0022~
SE*27*0021~
h End of Transaction Set, Ctl. No. 0022, contains 27
Transaction Set Ctl No. 0021 in SE doesn't match ST

(3) ST*835*0021~
Can't find Transaction Set 835 in Standard 837P0002 (004010X098)
Only limited checking using dictionaries can be done

(4) SE*25*0021~
h End of Transaction Set, Ctl. No. 0021, contains 27 Segments
Transaction Set segment total 25 Incorrect - should be 27

//HIPAA/DSR/Comp Guides/837 19 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

Appendix B – Testing Requirements

Testing Requirements

EDI Trading Partner Testing

PacifiCare has adopted the Workgroup for Electronic Data Interchange (WEDI) Strategic National Implementation Process (SNIP) Testing Sub-Workgroups
recommendations on the types of testing that need to occur in order to remain in line with the health care industry’s testing recommendations. Initially, the types of
testing that PacifiCare strongly recommends for the 837 Transaction Sets include:
¾ Type 1: EDI syntax integrity testing – Testing of the EDI file for valid segments, segment order, element attributes, testing for numeric values in numeric
data elements, validation of X12 or NCPDP syntax, and compliance with X12 and NCPDP rules. This will validate the basic syntactical integrity of the EDI
submission.
¾ Type 2: HIPAA syntactical requirement testing – Testing for HIPAA Implementation Guide-specific syntax requirements, such as limits on repeat counts,
used and not used qualifiers, codes, elements and segments. Also included in this type is testing for HIPAA required or intra-segment situational data elements,
testing for non-medical code sets as laid out in the Implementation Guide, and values and codes noted in the Implementation Guide via an X12 code list or
table.
Third-Party Certification Systems and Services (TPCSS)
TPCSS vendors provide test data and testing services for anyone in need of testing compliance of their HIPAA transactions. PacifiCare requests that Trading
Partners test with a TPCSS and provide evidence of such testing. EDI submitters that have tested their 837 Transaction Sets with a certification system may
provide a certificate of compliance. The certificate should specify the different types of testing passed or provide us with a certification website that indicates you
have successfully passed certain types of certification testing.

//HIPAA/DSR/Comp Guides/837 20 08/29/03

 PacifiCare Health Systems – 837 Professional Transaction Companion Guide
Combined 837 Professional Transaction Set – 004010X098 & 004010X098A1

PacifiCare will collect evidence of the Third-Party Certification during the Trading Partner Setup process.

//HIPAA/DSR/Comp Guides/837 21 08/29/03