The Health Insurance Portability and Accountability Act (HIPAA) mandates the standardization of EDI formats for health care data transmission, which includes claims, remittance, eligibility, and claim status inquiries. HIPAA regulations replace the CMS 1500 and UB04 Claims formats with ASC X12N 837 Transactions.
The Blue Cross and Blue Shield of North Carolina (Blue Cross NC) Companion Guides are available to assist trading partners in understanding Blue Cross NC code and situation handling used in processing the ANSI ASC X12N Transactions. The X12 version 5010 of the Companion Guide is available.
The Trading Partner Agreement establishes the formal business relationship between a sender / receiver of electronic files and Blue Cross and Blue Shield of North Carolina.
New trading partners will receive this agreement electronically after the new trading partner has submitted the Electronic Connectivity Request (ECR) form to Blue Cross NC eSolutions and eSolutions has processed the request.
Complete one of the ECR forms and submit to eSolutions to begin the process.
Any entity wishing to exchange HIPAA (X12) files with Blue Cross NC must submit the appropriate ECR form. Select the appropriate forms based on your role as either a healthcare provider or a clearinghouse / billing service.
If you do not currently exchange HIPAA (X12) files with Blue Cross NC or you want to add a transaction type to the transactions you currently exchange, complete this ECR form and submit it online.
If you do not currently exchange HIPAA (X12) files with Blue Cross NC or you want to add a transaction type to the transactions you currently exchange, complete this ECR form and submit it online.
Don't use this form to request an Electronic Remittance Advice (835 transaction).
Use this form to request receipt of an Electronic Remittance Advice (835) if you need to submit the request via fax. You will need to print and fax this form to Blue Cross NC. See the 835 Enrollment Form Guidelines on the form for instructions.
Use this form when giving Medicare services to members who have additional coverage with a different Blue Cross and Blue Shield (BCBS) plan.
Blue Cross NC electronically forwards 835 remittances for Medicare crossover claims received from other BCBS plans to providers with NPIs registered with Blue Cross NC to receive them.
You must also receive 835 Remittances (not associated with Medicare) to be able to submit this form.
Trading Partners who send electronic transmissions directly to Blue Cross NC must test for HIPAA compliance before they can transmit to Blue Cross NC production environment. Blue Cross NC offers free testing for its trading partners through a web-based application. This testing tool provides analysis of test files, specific information on errors, and enables users to keep a history of files tested. The site can also be used to run production files for senders who would like to verify the compliance of their files prior to transmission.
Trading partners must register at the website prior to submitting files for testing. For detailed information about registering and submitting test files, download the Instructions for HIPAA testing with Blue Cross NC Community Portal (PDF).
| Topic | Chapter |
|---|---|
| Introduction to the Blue Cross NC Companion Guide for Version 5010 EDI Transactions (for all Trading Partners) | Chapter Version 2.5 (PDF) |
| 837 Institutional Health Care Claim (Version 5010) | Chapter Version 5.7 (PDF) |
| 837 Professional Health Care Claim (Version 5010) | Chapter Version 5.11 (PDF) |
| 270 and 271 Health Care Eligibility Inquiry and Response (Version 5010) | Chapter Version 3.2 (PDF) |
| 276 and 277 Claim Status Request and Response (Version 5010) | Chapter Version 1.5 (PDF) |
| 278 Health Care Services Review and Response (Version 5010) | Chapter Version 1.1 (PDF) |
| 835 Health Care Claim Payment/Advice (Version 5010) (for participating providers only) | Chapter Version 3.0 (PDF) |
| Blue Cross NC HIPAA Glossary | Chapter Version 2.0 (PDF) |
You can expect to receive the following electronic format transactions or reports as a result of your batch transmission:
This sample document illustrates the Blue Cross NC proprietary Claims Audit Report. Providers can download the Claims Audit Reports from their Blue Cross NC electronic mailboxes or receive them from their clearinghouses. The Claims Audit Report is returned for 837 Health Care Claim transactions only.
This sample provides illustrations of three different 999 Functional Group Acknowledgments. The 999 transaction serves as both a positive acknowledgment and a report of Implementation Guide errors within a Functional Group (GS / GE) or a Transaction Set (ST / SE).
This sample provides two illustrations of the TA1 Interchange Acknowledgment Transaction. The TA1 may provide a positive acknowledgment of the transmission or a negative acknowledgment that includes a report of Implementation Guide errors within an Interchange Control (ISA / IEA).
Electronic transactions are data exchanges sent electronically between payers, healthcare providers, and clearinghouses. HIPAA requires the use of specific standards for these transactions, which include:
- Claims and claim status
- Remittances (such as payments and explanations of payment)
- Eligibility inquiries and responses
- Authorizations and referrals
Using these standards helps ensure transactions are processed consistently and accurately across healthcare systems.
HIPAA is a federally mandated law. If providers do not make an effort to become compliant, they will be subject to penalties.
Implementation Guide edits address issues such as the presence of required fields or fields required under certain conditions, the validation of data structure (e.g. alpha-numeric requirements, field length), and the correct usage of medical and non-medical code sets. Implementation Guide edits are identified through the TA1 or 997 Acknowledgment transactions.
Blue Cross NC business edits address only those data elements that are required for business processing. For health care claims, our business edits are defined in the context of the 837 transactions in both Chapters 1 and 2 of the Blue Cross NC Companion Guide to EDI Transactions. The Blue Cross NC business edits are also listed in Appendices B and C of the Blue Cross NC Companion Guide to EDI Transactions. Business edits are identified by either the Blue Cross NC Claims Audit Report (for 837 Claims filings) or by the paired transaction to a 270, 276, or 278. Those transmitting 834 files are notified of business edits via phone or email.
What’s required depends on whether you send transactions directly to us or transmit them through another organization.
If you send transactions directly to Blue Cross NC:
You’ll need to complete the following steps:
- Complete a Blue Cross NC Trading Partner Agreement (TPA). A TPA is required even if testing isn’t needed.
- Return an original copy of the TPA, signed by authorized personnel, to Blue Cross NC EDI Services.
- Complete an Electronic Connectivity Request (ECR) form for each transaction type you want to transmit.
If you send transactions through a clearinghouse, billing service, or service bureau:
- Complete an ECR form for each transaction type you want to submit or receive.
Your clearinghouse or service bureau may complete and submit the ECR form on your behalf.
TPA and ECR forms and additional instructions are available on the HIPAA information page.
The TPA outlines the roles and responsibilities that bind both Blue Cross NC and its trading partner, to ensure secure electronic transmissions. A TPA is not required by HIPAA, but the ASC Insurance Subcommittee that was charged with developing the Implementation Guides for EDI transactions strongly recommends that trading partners have binding agreements to provide security and assurance in the transfer of electronic information (See Section 1.1.1 of any ASC X12 Implementation Guide). Blue Cross NC has made a business decision to make trading partner agreements a requirement for EDI transmission based on this recommendation.
If you or an organization transmitting on your behalf sends transactions directly to us, a Blue Cross NC Trading Partner Agreement (TPA) is still required. Our TPA is designed to be comprehensive and is intended to address the legal and operational requirements for trading partners that submit direct transmissions to us.
No. However, a newly credentialed practitioner should be assigned a Blue Cross NC Provider Identifier Number by Network Management, another department of Blue Cross NC. Contact your local Network Management field consultant for more information.
You can call the eSolutions HelpDesk at 888-333-8594 to verify the status on your Trading Partner Agreement or ECR.
Right now, only one HIPAA‑compliant transaction version is available for transmission. However, as new versions are approved in the future, multiple version options may be available. Each version will have its own requirements, so including the transaction version number on your ECR form helps ensure we know which version you’re submitting and can process your transmissions correctly.
If you are a company that sends transactions on behalf of health care providers or you are a large provider institution that submits transactions on behalf of multiple provider groups, you will need to identify each group Blue Cross NC Provider ID for which you transmit files. However, you can send all group provider identifiers for which your organization is responsible on one form, using additional sheets of paper if necessary. However, separate forms must be submitted for 837 Institutional Provider Identifiers and 837 Professional Provider Identifiers.
We consider new suppliers based on current business needs, existing contractual relationships, and the supplier’s products and services.
Contract duration varies. When a contract is up for renewal, Blue Cross NC may invite qualified suppliers to participate in a bid opportunity. Blue Cross NC reserves the right to continue pre-existing relationships without conducting new bids.
Certification means your organization has been reviewed and confirmed by a third-party certifying agency as a diverse-owned business. Suppliers are responsible for acquiring and maintaining valid certification.
Yes. However, if the vendor receiving the 835 is different from the one submitting your 837 claims, you must complete a separate 835 Electronic Connectivity Request (ECR) form.
Paired response transactions – including 271, 277, and 278‑11 – are sent back to the entity that submitted the original transaction (270, 276, or 278‑13).
The 835 remittance is returned either:
- To the sender of the 837 claim, or
- To the entity identified on the 835 Electronic Connectivity Request (ECR) form, if the remittance should be delivered to a different recipient.
No. We can’t determine whether your clearinghouse or billing service has begun testing. You’ll need to contact your clearinghouse or billing service directly for that information.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
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