5010 Claims Companion Guide (837)
Your Guide to Transacting with Capario
Updated: October 16, 2012
Table of Contents
Welcome to Capario
Essential Capario Information
Getting Started with Capario
Sales and Contracting
Communication and Connectivity
Set Up and Implementation
Enrollment
5010 X12 Guidelines
Testing for Submitters
5010 Testing Checklist
Capario 5010 Testing System
Logging into the Testing Tool
Portal Testing Tool: Supported Transactions
Test Results
Using 5010 with Capario
Enveloping
Tips for 5010 Success
Acknowledgement and Reports
999 and 997 Informational and Functional
277CA
Welcome to Capario
Capario is a HealthCare transactions processing network with an extensive network of direct
connections to payers nationwide. We offer cutting-edge, web-based technology. Capario enables
healthcare organizations to expedite revenue cycle processes while improving cash flow,
streamlining workflow, and increasing productivity.
From real-time transaction processing to electronic payment information to extensive business
intelligence reporting, Capario delivers vital and far-reaching benefits to your revenue cycle,
advancing the business objectives of physician practices, insurance providers, and industry partners.
Best known for being dedicated to providing healthcare's best revenue cycle management solutions
available; Capario is committed to developing progressive revenue cycle management solutions,
supported by our industry-leading customer service.
For more information contact Capario Sales: 800-586-6870 or Sales@capario.com
Essential Capario Information
Contact Information
Capario Sales: 800-586-6870 or Sales@capario.com
Provider Customer Service: 800-792-5256 or EDI@capario.com
Payer Customer Service: 800-586-6938 or PayerServices@capario.com
Partner Customer Service: 800-246-0203 or Partner@capario.com
Medisoft/Lytec VAR Service: 800-706-5306 or VARsupport@Capario.com
MediSoft/Lytec Customer Service: 800-218-1500 or Msupport@Capario.com
Enrollment: 800.792.5256 opt 1 or provider.enrollment@capario.com
5010 Questions - Submitters:5010@capario.com
5010 Questions - Payers: 5010Payers@capario.com
For more contact information please visit our home page: http://www.capario.com/contact.aspx
Processing Hours
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Portal - Available 24/7 -- Availability may be affected by a weekly maintenance period
conducted Saturday from 2-8 a.m. PT
Claim Submission - Available 24/7
Claim Processing - Available every business day -- Claims received before 3 p.m. PT are
processed and sent to the payers that evening. Claims received after 3 p.m. PT are sent the
next business day.
Real Time (Eligibility, CSI) – Availability varies based on payer
ERAs - Available as they are received from payers
Payer Acknowledgements and Reports - Available every business day by 10 p.m. PT
Business Hours
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Enrollment Support - 5 a.m. PT to 4 p.m. PT.
EDI Support for Submitters, Vendors and Billing Providers - 5 a.m. PT to 5 p.m. PT
Payer Support - 7 a.m.PT to 3 p.m. PT
Capario's Resource Center and Payer List
Capario's Resource Center includes: Enrollment information, Companion Guides, Payer List and
more. Capario Resource Center
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Getting Started with Capario
Included in this section are the steps needed so you can work with Capario to:
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Submit transactions
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Receive acknowledgments and reports
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Receive ERAs
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Conduct RT inquiries.
Sales and Contracting
An executed contract must be completed prior to submitting any test transactions to Capario. Please
contact our Sales Department regarding the process to complete a contract.
Capario Sales: 800-586-6870 or Sales@capario.com
Communication and Connectivity
In order to protect PHI all our communication protocols provide HIPAA compliant data security so
that patient data received from submitters and sent to payers is protected. The security method or
mechanism varies based on the COMM type. For some the data is encrypted and for others the
connection is encrypted.
We offer the following communication protocols:
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SFTP (SSH)
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FTPS (SSL)
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FTP/PGP
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Portal
For complete information regarding Capario Communication types: Click Here
File Naming Conventions
For the transition to 5010, Capario’s file naming conventions will be:
999:
Format: CID_Filename.999
Sample File Name: 99999999_CLM9263226.CLM.999
277CA:
277CA files currently use the same naming convention used for REC and INS reports.
Format: ClientID.DATETIME.REC
Format: ClientID.DATETIME.INS
Sample File Name: 99999999.20110807145017.REC
Sample File Name: 99999999.20110807145017.INS
ERA:
Format: SITEID_PAYERID_PROCESSDATE_SEQUENCE NUMBER.(ERA/TRN/PRA)
Sample File Name: GD999999_61101_20110705_000108.era
Sample File Name: GD999999_61101_20110705_000108.trn
Sample File Name: GD999999_61101_20110705_000108.pra
REC:
Format: ClientID.DATETIME.REC
Sample File Name: 99999999.20110807145017.REC
INS:
Format: ClientID.DATETIME.INS
Sample File Name: 99999999.20110807145017.INS
ANC:
Format: ClientID.DATETIME.ANC
Sample File Name: 99999999.20110807145017.ANC
New Client Implementation
During implementation you will be assigned a dedicated EDI Analyst who will set-up your account,
train you on how to submit your EDI transactions and work with you during the testing period.
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You will be able to test files 24/7. Your EDI Analyst will be available for live support during
normal business hours.
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Test results will take 30 to 60 minutes.
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For all test claims the Capario claim trace number ends in “TST”. The Capario claim trace
number consists of 15 alpha/numeric characters: Day of the year (3 numbers) + sequencing
number (9 numbers) + TST. Example 109001860410TST where 109 is the day of the year
and 001860410 is the sequencing number.
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Test report will be placed in the reports directory with an .REC extension.
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Claims submitted to the test environment are processed against Capario production edits.
Claims rejected during testing will also reject during production unless the improper data is
corrected.
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Rejections during testing are only from Capario edits as the claims are not forwarded to the
payer. You may experience additional payer rejections after your transactions move to a live
production status.
Enrollment
Capario offers two ways for you to start and manage the enrollment process. Enrollment is started
during implementation.
1) Capario's Portal includes a web based Enrollment tool that prints agreements with your
information and helps you manage enrollment progress.
2) If you are not a Portal user you can obtain all agreements from our web site then print and
complete them at your office. Based on payer requirements the agreements are sent to the
payer(s), or Capario, if we need to sign it. The payer list, with agreements and instructions, is
located on our Resource Center. Click here.
Following contracting, Portal and Non-Portal users can start the manual enrollment process from our
Resource Center. Since the enrollment process can take up to 45 days some portal customers use
this "manual" method to get the process started. After completing Portal training Portal users can
transition their enrollment tasks over to the Portal Enrollment tool.
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5010 X12 Guidelines
Trading Partners must use the ASC X12 National Implementation Guides, known as Technical
Report Type 3 (TR3), adopted under the HIPAA Administrative Simplification Electronic Transaction
rule and standard EDI Companion guidelines for development of the EDI transactions.
The most current national standard code lists applicable to the EDI transactions is available from the
Washington Publishing Company web site http://www.wpc-edi.com/content/view/817/1
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005010X222A1 - Health Care Claim: Professional (837P)
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005010X223A2 - Health Care Claim: Institutional (837I)
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005010X221A1 - Health Care Claim Payment/ Advice (835)
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005010X212 - Health Care Claim Status Request and Response (276/277)
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005010X214 - Health Care Claim Acknowledgment (277CA)
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005010X279A1 - Health Care Eligibility Benefit Inquiry and response (270/271)
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005010X231 - Implementation Acknowledgment For Health Care Insurance (999)
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Testing for Submitters
To facilitate self-testing, Capario has developed a 5010 testing tool on our portal. The Capario
testing tool can be used in two stages, to test 5010 files.
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Stage 1 - This stage validates the 5010 file for SNIP Type 1-2 or SNIP Type 1-5 to ensure
your file is structurally compliant. Here are the WEDI SNIP Testing Standards (1 through 5)
used to determine HIPAA compliance.
 Type 1: EDI syntax integrity testing
 Type 2: HIPAA syntactical requirement testing
 Type 3: Balancing
 Type 4: Situation testing
 Type 5: External code set testing
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Stage 2 - Payer Specific Validation – Performs the payer validation that will be used on the
production files. Validations are payer specific, based on the payer edits in place at Capario
on the day of the test. This process will produce the most accurate view of how your files will
process when you submit to our production environment.
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Although not required, Capario strongly recommends completing the payer specific testing
prior to submitting any 5010 transactions in production. Following successful completion of
stage 1 and 2, submitters will be ready to submit in 5010. To help expedite your testing and
increase your success rate, please review the checklist prior 5010 testing and moving to
production.
5010 Testing Checklist
Overview
To help you expedite your testing and increase your success rate please review this checklist before
submitting test files to the 5010 Test Tool.
5010 Software Readiness
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Is my system ready to accommodate the 5010 transactions?
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Can my current system accommodate both 5010 Claim Submission and Reporting?
Portal Testing Tool
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Obtain Logon and Password
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Stage One – Basic HIPAA Validation
 SNIP Type 1-2
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Stage One - Extended HIPAA Validation
 SNIP Type 1-5
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Stage Two – Payer Specific Validation
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Reporting Types test
Production
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Did I test a typical production day of claims?
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Have I tested all the payers I submit too?
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Have I tested all reporting/responses in my system?
Capario 5010 Testing System
The Capario 5010 Testing tool enables Capario submitters to validate 5010 transaction formats and
content before submitting 5010 transactions to the Capario production system. Although various
levels of validation testing are offered there is no need to perform each type of test in order.
Although not required Capario strongly recommends completing the payer specific testing prior to
submitting any 5010 transactions in production.
Login to the Testing Tool
For Portal Users
For active submitters who are Portal Users, Capario added "5010 Test Service” to their existing
portal profiles.
For Non-Portal Users
For non-portal users, Capario created a new Portal profile to include one service - “5010 Test
service”. Capario has created a 5010 Testing Tool user name and temporary password for all nonPortal clients. To access:
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Go to: https://portal.capario.net
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Your Provider Portal User Name is: 5010_test_12345678 where 12345678 is your
Capario Client ID
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Temporary Password: 5010_test
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After login you will be prompted to update your password to a new password of your choice
and to create a password reset reminder question and answer.
Portal Testing Tool: Supported Transactions
837P – Professional Claims: (SNIP Type 1 to 5)
837I - Institutional Claims (SNIP Type 1 to 5)
837P – Professional Claims: (Payer Level Testing)
837I - Institutional Claims : (Payer Level Testing)
835 – Electronic Remittance Advice
277CA – Claim Status Response - Batch
Test Results
Test results for claim files will be delivered in a human readable HTML file containing the error
messages. Each test will be held and processed separately with a corresponding HTML file upon
completion of the test.
ERA files will be delivered to the test system for your account automatically. They will be maintained
for a maximum of 30 days from delivery. These are 5010 duplicates of the 4010 ERA files delivered
to your production mailbox.
The Healthcare Claims Acknowledgement (277CA) will be delivered to the test results area for any
claim file submitted with the 277CA test result option selected.
Using 5010 with Capario
Enveloping
This section contains some information needed to create the ISA/IEA, GS/GE and ST/SE control
segments for transactions to be submitted to Capario.
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Interchange Control (ISA/IEA) and Function Group (GS/GE) envelopes must be used as
described in the TR3 documents.
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Existing X12 submitters may continue using the current values in Interchange Sender ID and
Receiver ID in ISA06 and ISA08, as well as Application Sender’s and Receiver codes in
GS02 and GS03. New X12 submitters may use their Capario assigned Client id in ISA06
and GS02, and Capario Tax id “263086998“ in ISA08 and GS03, along with a value of “ZZ”
in ISA05 and ISA07.
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Capario only supports one interchange (ISA/IEA envelope) per incoming transmission (file).
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Multiple Functional Groups (GS/GE) may be used within an ISA/IEA as long as the GS08
Version/Release/Industry Identifier Code remains constant throughout Functional Groups.
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Acknowledgement and Reports - ASC X12
Acknowledgments
999 and 997 Informational and Functional
Batch submitters have the option of receiving file level 999 or a 997 acknowledgement report from
Capario for their 837 file submissions. Based on submitter request Capario can return an
Implementation Acknowledgment for Health Care Insurance (999) or a Functional Acknowledgement
(997) for each Functional Group (GS - GE) envelope that is received in a batch mode.
277CA
The Claim Acknowledgment Transaction (277CA) is used to return a reply of "accepted" or "not
accepted" status for claims or encounters submitted via the electronic claim transaction in batch
mode.
Acceptance at this level is based on the electronic claim TR3 and front-end edits, and will apply to
individual claims within an electronic claim transaction. For those claims not accepted, the Health
Care Claim Acknowledgement (277CA) will detail additional actions required of the submitter in
order to correct and resubmit those claims.
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Does this page need revision? If so please send an email to: EDI@capario.com.