Healthcare Claim Acknowledgement

Published November 2004

Companion Guide 277 Health Care Claim Acknowledgement

Release 1.0

X12N 277(Version 4040X167) Health Care Claim Acknowledgement

Implementation Guide

277 Health Care Claim Acknowledgement

2 Published November 2004

Revision History

Date Release Appendix name/ loop & segments

Description



TABLE OF CONTENTS

1. INTRODUCTION........................................................................................................................................................4

1.1 INTENDED AUDIENCE...............................................................................................................................................4 1.2 PURPOSE OF THE COMPANION GUIDE.......................................................................................................................4

2. GENERAL INFORMATION .....................................................................................................................................4

2.1 CONFIDENTIALITY, PRIVACY AND SECURITY ...........................................................................................................4 2.2 SECURITY STATEMENT.............................................................................................................................................5

3. CONTACTS .................................................................................................................................................................5

3.1 PRIVACY CONTACT ..................................................................................................................................................5 3.2 TRANSACTION CONTACT: ........................................................................................................................................6 3.3 PROVIDER RELATIONS .............................................................................................................................................6

4. ESTABLISHING CONNECTIVITY WITH NHP ...................................................................................................7

4.1 INITIATING EDI SETUP.............................................................................................................................................7 4.2 TRADING PARTNER SETUP .......................................................................................................................................7 4.3 TESTING ...................................................................................................................................................................8 4.4 PRODUCTION............................................................................................................................................................9

5. TECHNICAL SPECIFICATIONS OF THE TRANSACTION ............................................................................10

HEALTH CARE CLAIM ACKNOWLEDGEMENT……………………………………………………………………….10

APPENDIX A – REJECT REASON CODES ............................................................................................................ .11

APPENDIX B – TRADING PARTNER AGREEMENT ...........................................................................................12

APPENDIX C - NHP SPECIFIC 277 HEALTH CARE CLAIM ACKNOWLEDGEMENT MAP …..…………14



1. Introduction

1.1 Intended Audience This companion guide is intended for the business and technical areas, within or on behalf of a provider organization, responsible for the testing and setup of electronic claims submissions to Neighborhood Health Plan. In addition, this information should be communicated to, and coordinated with, the provider's billing office in order to ensure that the required billing information is provided to its billing agent/submitter. This guide supports the submission of X12N 277 Health Care Claim Acknowledgement (004040X167)

1.2 Purpose of the Companion Guide This document has been prepared as a Neighborhood Health Plan specific companion guide to the 277 Health Care Claim Acknowledgement transaction sets. The primary purpose of the document is to assist the user with the acknowledgement of a valid 837 claims transaction and NHP’s status of the file.

2. General Information

2.1 Confidentiality, Privacy and Security Maintaining the confidentiality of personal health information has been, and continues to be, one of NHP’s guiding principles. NHP has a strict Confidentiality Policy with regard to safeguarding patient, employee, and health plan information. All staff are required to be familiar with, and comply with NHP’s policy on the Confidentiality of Member Personal and Clinical Information to ensure that all member information is treated in a confidential and respectful manner. The policy permits use or disclosure of members’ medical or personal information only as necessary to conduct required business and perform care management, approved research, quality assurance and measurement activities when authorized to do so by a member or as required by law. In order to comply with our own internal policies and the provisions of the Health Insurance Portability and Accountability Act, 1996 (HIPAA), NHP has outlined specific requirements applicable to the electronic exchange of protected health information (PHI) including provisions for: • Maintaining Confidentiality of Protected Information



• Confidentiality Safeguards • Security Standards • Return or Destruction of Protected Information • Compliance with State and Federal regulatory and statutory requirements • Required disclosure • Use of Business Associates • Implementing trading partner agreements prior to receiving electronic files

2.2 Security Statement NHP has implemented a best practice approach to protecting the integrity and availability of protected health information. NHP is evaluating its current standards for the exchange of protected health information, electronic storage and/or transmission over telecommunications systems/networks based on the current HIPAA security regulations to determine whether updates or changes to established protocols will be needed.

3. Contacts

3.1 Privacy Contact For privacy questions please contact:

Privacy Officer Neighborhood Health Plan 253 Summer Street Boston, MA 02210

617-772-5500 or 1-800-433-5556 (Toll-free) and ask for Privacy Officer



3.2 Transaction Contact: The NHP E-commerce department is the contact for all transaction-related questions. For user set up and to establish testing, please contact:

E-commerce Neighborhood Health Plan 253 Summer Street Boston, Ma. 02210

617-772-5550 or 1-800-433-5556 (Toll-free) and ask for E-commerce E-Mail : [email protected]

3.3 Provider Relations Should you need to have additional providers set up, please contact your Provider Relations representative.

mailto:[email protected]



4. Establishing Connectivity with NHP

4.1 Initiating EDI Setup In order to receive a 277 Health Care Claim Acknowledgement file from NHP, you would have had to submit an 837 Professional or Institutional file.

4.2 Trading Partner Setup Providers wishing to receive electronic claims acknowledgements from NHP should contact the NHP E-Commerce Department via e-mail or telephone to initiate a setup request. A Trading Partner Agreement Amendment form (Appendix B) is required to initiate a trading partner change. If any of the information on the Authorization Form changes (i.e. request for U277 files), a new form must be completed and submitted to NHP’s E-Commerce Department. NHP’s E-Commerce Department will return an EDI authorization to the Trading Partner with all the necessary information to submit electronic transactions. The information will include:

• An assigned default user ID and password and a mailbox (folder) for file drop off and retrieval

• Submitter (ISA06) and the Submitter Application ID (GS02) – Trading Partner ID NHP will return acceptance file for transmissions only from authorized Trading Partners who have signed an NHP Trading Partner Agreement. Claim submission files for providers who submit without a Trading Partner Agreement in place will be rejected with a 997 only. The NHP E-Commerce Coordinator will then contact you to establish a valid Trading Partner Agreement. Submitters should include a script in their file pick up process that deletes the file from the server. (An archive copy of all files is stored and backed up daily by NHP. Eliminating the file from the server will improve overall performance.)



4.3 Testing NHP will test this transaction with trading partners using data generated from submitted 837 transactions. If the trading partner is already in production with 837 claims submissions a 277 Health Care Claim Acknowledgement file will be placed in their production OUT box for the corresponding production claims submitted. If the trading partner is submitting test 837 data then the resultant 277 Health Care Claim Acknowledgement file will be placed in their test OUT box corresponding to the test 837 file that was submitted.



4.4 Production NHP will monitor closely the first few production runs to ensure successful receipt of the file. NHP RESERVES THE RIGHT TO REQUIRE RE-TESTING IF IT IS DETERMINED THAT A SUBMITTER IS RECEIVING/GENERATING AN UNACCEPTABLE VOLUME OF ERRORS OR TYPES OF ERRORS.



5 Technical Specifications of the Transaction 277 Health Care Claim Acknowledgement NHP uses a proprietary front-end processor. Files that are accepted by the NHP ANSI Translator are not necessarily submitted to the claims adjudication system for processing. NHP will return a 277 Health Care Claim Acknowledgement within twenty-four (24) hours of the file receipt but generally the file is available within two hours. This initial claims receipt will include an acknowledgement of claims accepted and or rejected. • Initial Claims Receipt 277 Response - STC01 valid codes are:

• A2 Claim has been received and forwarded to the claims adjudication system. • A3 Claim has been rejected and has not been sent to the adjudication system. Please refer

to Appendix A for a list of reject reasons. The submitter should review the 277 Health Care Claim Acknowledgement to verify that all claims have been accepted and sent for processing or rejected. The 277 Health Care Claim Acknowledgement is not a HIPAA-mandated transaction but is supported by NHP. At this level, NHP will pass good claims to the claims system and pass back claims that failed NHP business edits. Appendix C has a full listing of all Loops and Segments used by NHP with the appropriate values.

If your EDI file was rejected, and you are not sure why or how to correct it, it is important to contact the E-Commerce Department as soon as possible to ensure that your claim file is resubmitted before the filing limit expires. THE 277 HEALTH CARE CLAIM ACKNOWLEDGEMENT ELECTRONIC FILE AND HUMAN READABLE REPORT WILL BE SENT TO YOUR OUT FOLDER FOR RETRIEVAL BY YOU.

Your pick up file script should include a delete script in your file process. Delete the file out of your OUT mailbox after you have successfully retrieved it. THE SUBMITTER SHOULD REVIEW THE 277 HEALTH CARE CLAIM ACKNOWLEDGEMENT TO VERIFY THAT ALL BATCHES HAVE BEEN ACCEPTED AND SENT FOR PROCESSING TO THE NHP ADJUDICATION SYSTEM.

NHP will also offer the 276/277 claims status request response through NEHEN and NHPnet. NHP will work with clearing house trading partners to determine their readiness to accept a 276/277 request response.

Refer to NHP’s Companion Guide for the 276/277 request response transaction.



Appendix A – Reject Reason Codes Error Code

Description 21 Missing or invalid information. 33 Subscriber and subscriber id not found. 73 Payment made to entity, assignment of benefits not on file. 88 Entity not eligible for benefits for submitted dates of service. 121 Service line number greater than maximum allowable for payer.

(NHP will only accept one LIN segment per SV1 segment.) 122 Missing/invalid data prevents payer from processing claim. 135 Entity's commercial provider id. 142 Entity's license/certification number. 153 Entity's id number.

Identifier Code = HK (Insured/Subscriber) 158 Entity's date of birth

Identifier Code = HK (Insured/Subscriber) 218 NDC number. 232 Admitting diagnosis. 251 Total anesthesia minutes. 254 Primary diagnosis code. 255 Diagnosis code. 258 Days/units for procedure/revenue code. 277 Paper claim. 448 Invalid billing combination. See STC12 for details. This code should only be

used to indicate an inconsistency between two or more data elements on the claim. A detailed explanation is required in STC12 when this code is used. (STC12 contains the correct ID Number to submit)

453 Procedure Code Modifier(s) for Service(s) Rendered 454 Procedure code for services rendered. 455 Revenue code for services rendered. 456 Covered Day(s) 465 Principal Procedure Code for Service(s) Rendered



Appendix B – Trading Partner Agreement Amendment

Request for Trading Partner Number

Setup for Filing Electronic Claims to Neighborhood Health Plan Please provide the following Information: Type of Account: New X Existing/Revision to TPA Name of Person submitting this form: Phone Number: Fax Number: Email Address:

Trading Partner/Submitter Information: Practice Type:

Community Health Center Clinic Hospital/Facility HealthCare Provider Office Clearing House Billing Service*

*Please Note: If a Billing Service is going to submit transactions on your behalf, NHP needs an authorization on the provider’s corporate letterhead, allowing NHP to release your financial/patient information. Health Care Provider Information: Name: Practice Tax ID Number

Address: City: State: Zip Contact Person Phone Number FAX E-mail address If Payee Information is Different from Provider Information: Name of Payee: Address: City: State: Zip

NHP Vendor ID Number Payee Tax ID Number



Claims Filing Software Vendor Information: Vendor Name: Address: City: State: Zip Vendor Contact Person Phone Number FAX Vendor E-mail address Type of transactions that you wish to be authorized for: Transaction With Addenda changes

Claims Professional 837P version 4010A Claims Institutional 837I version 4010A Remittance 835 version 4010A Claims Status 276/277 version 4010A Eligibility 270/271 version 4010A Referral/Authorizations 278 version 4010A Enrollments 834 version 4010A Premium Payments 820 version 4010A Unsolicited 277 version 4040

Communication Protocol Type:

FTP/PPP NEHEN Other Protocol, Please contact e-Commerce Department of NHP at 617-772-5550

I, _________________________________ agree that in reference to 45 C.F.R. section §162.915 Trading Partner Agreements of the HIPAA regulations, that we will not do any of the following: (a) Change the definition, data condition, or use of a data element or segment in a standard. (b) Add any data elements or segments to the maximum defined data set. (c) Use any code or data elements that are either marked "not used" in the standard’s implementation specification or are not in the standard’s implementation specification(s). (d) Change the meaning or intent of the standard’s implementation specification(s). _____________________________ Print Name _____________________________ Print Title _____________________________ _____________________________ Signature Date



Appendix C – NHP-Specific 277 Acknowledgement Map APPENDIX C - NHP SPECIFIC U277 MAP R=Requires, S=Situational, N=Not Used

Loop R or S

Seg- ment

ANSI U277 Field Name Allowable Data Values IG Page

Field Size Min Max

Business Rule

R INTERCHANGE CONTROL HEADER

R ISA01 Auth Information Qualifier 00 No auth info present 03 Additional data information

B3 2 2

R ISA02 Authorization Information B4 # 10 R ISA03 Security Info Qualifier 00 No info present

01 Password B4 2 2

R ISA04 Security Information B4 # 10 R ISA05 Interchange ID Qualifier ZZ Mutually Defined B4 2 2 R ISA06 Interchange Sender ID B4 # 15 R ISA07 Interchange ID Qualifier ZZ Mutually Defined B5 2 2 R ISA08 Interchange Receiver ID B5 # 15 R ISA09 Interchange Date YYMMDD B5 6 6 R ISA20 Interchange Time HHMM B5 4 4 R ISA11 Repetition Separator B5 1 1

R ISA12 Interchange Control Version No.

00404 B5 5 5

R ISA13 Interchange Control No. B6 9 9 R ISA14 Acknowledgment

Requested 0 No acknowledgement requested 1 Acknowledgement requested

B6 1 1

R ISA15 Usage Indicator P Production data T Test data

B6 1 1

R ISA16 Component Element Separator

B6 1 1

R FUNCTIONAL GROUP HEADER

R GS01 Functional ID Code HN Health Care Claim Status Notification (277)

B8 2 2

R GS02 Application Sender's Code B8 2 15 R GS03 Application Receiver's

Code B8 2 15

R GS04 Date Format: CCYYMMDD B8 8 8



R GS05 Time Format HHMM (recommended), HHMMSS, HHMMSSD, HHMMSSDD

B8 4 8

R GS06 Group Control No. B9 1 9 R GS07 Responsible Agency Code X Accredited

Standards Committee X 12

B9 1 2

R GS08 Version/Release/Industry ID Code

004040X167 B9 1 12

R TRANSACTION SET HEADER

R ST01 Transaction Set Identifier Code

277 Health Care Claim Status Notification

32 3 3

R ST02 Transaction Set Control Number

32 4 9

R ST03 Implementation Convention Reference

004040X167 33 1 35

R BEGINNING OF HIERARCHICAL TRANSACTION

R BHT01 Hierarchical Structure Code

0085 Information Source, Information Receiver, Provider of Service, Patient

34 4 4

R BHT02 Transaction Set Purpose Code

08 Status 34 2 2

R BHT03 Reference Identification 35 1 50 R BHT04 Transaction Set Creation

Date 35 8 8 Format: CCYYMMDD

R BHT05 Time 35 4 8 Format: HHMM or HHMMSS or HHMMSSD or HHMMSSDD.

R BHT06 Transaction Type Code TH Receipt Acknowledgement Advice.

35 2 2

2000A R INFORMATION SOURCE LEVEL

R HL01 Hierarchical ID Number 37 1 12

N HL02

Hierarchical Parent ID Number 37 1 12

R HL03 Hierarchical Level Code 20 Information Source 37 1 2

R HL04

Hierarchical Child Code 1 Additional subordinate HL Data Segment in this Hierarchical Structure 37 1 1

2100A R INFORMATION SOURCE NAME



R NM101 Entity ID Code PR Payer 39 2 3

R NM102 Entity Type Qualifier 2 Non-Person Entity 39 1 1

R NM103 Name Last or Organization Name

39 1 60

N NM104 Payer Name First 39 1 35

N NM105 Payer Name Middle 39 1 25

N NM106 Payer Name Prefix 39 1 10

N NM107 Name Suffix 39 1 10

R NM108 Payer Identification Code

Qualifier PI Payer Identification 40 1 2

R NM109 Payer Identification Code 40 2 80

N NM110 Entity Relationship Code 40 2 2

N NM111 Entity Identifier Code 40 2 3

N NM112 Name Last or Organization

Name 40 1 60

2200A R TRANSMISSION RECEIPT CONTROL IDENTIFIER

R TRN01 Trace Type Code 1 Current Transimission Trace Numbers

41 1 2

R TRN02 Reference Identification 42 1 50 Start from 1 and incremental by 1 for every file.

N TRN03 Originating Company Identifier

42 # 10

N TRN04 Reference Identification 42 1 50 2200A R INFORMATION RECEIVER RECEIPT DATE

R DTP01 Date/Time Qualifier 050 Received 43 3 3 R DTP02 Date Time Period Format

Qualifier D8 Date Expressed in Format CCYYMMDD

44 2 3

R DTP03 Date Time Period 44 1 35 2200A R INFORMATION SOURCE PROCESS DATE

R DTP01 Date/Time Qualifier 009 Process 46 3 3 R DTP02 Date Time Period Format

Qualifier D8 Date Expressed in Format CCYYMMDD

46 2 3

R DTP03 Date Time Period 46 1 35



2000B R INFORMATION RECEIVER LEVEL

R HL01 Hierarchical ID Number 47 1 12

R HL02 Hierarchical Parent ID Number 48 1 12

R HL03 Hierarchical Level Code 21 Information

Receiver 48 1 2

R HL04 Hierarchical Child Code 1 Additional Subordinate HL Data Segment in this Hierarchical Structure 48 1 1

2100B R INFORMATION RECEIVER NAME

R NM101 Receiver Entity ID Code 41 SUBMITTER 50 2 3

R NM102 Receiver Entity Type Qualifier

1 Person 2 Non-Person Entity

50 1 1

R NM103 Receiver Name Last or Organization Name

50 1 60

S NM104 Receiver First Name 50 1 35

S NM105 Receiver Middle Name 51 1 25

S NM106 Receiver Name Prefix 51 1 10

S NM107 Receiver Name Suffix 51 1 10

R NM108 Receiver Identification Code Qualifier

46 Electronic Transmitter Identification Number (ETIN)

51 1 2

R NM109 Receiver Identification Code

51 2 80



N NM112 Name Last or Organization Name

51 1 60

2200B R TRANSMISSION RECEIPT CONTROL IDENTIFIER

R TRN01 Trace Type Code 2 Referenced Transaction Trace Numbers

52 1 2

R TRN02 Reference Identification 53 1 50 N TRN03 Originating Company

Identifier 53 # 10

N TRN04 Reference Identification 53 1 50



2200B R INFORMATION RECEIVER STATUS INFORMATION

R STC01 HEALTH CARE CLAIM STATUS

54 * *

R STC01 - 1

Category Code A2 Good 55 1 30

R STC01 - 2

Status Code 19 Good 56 1 30

S STC01 - 3

Entity Identifier Code 56 2 3

R STC01 -4

Code List Qualifier Code 65 Health Care Status Code

57 1 3

R STC02 Date 57 8 8 R STC03 Action Code WQ Accept 57 1 2 R STC04 Monetary Amount 58 1 18 Sum of 837 2300 clm02 N STC05 Monetary Amount 58 1 18 N STC06 Date 58 8 8 N STC07 Payment Method Code 58 3 3 N STC08 Date 58 8 8 N STC09 Check Number 58 1 16

S STC010 HEALTH CARE CLAIM STATUS

58 * *

R STC10 -1

Industry Code 58 1 30

R STC10 -2


S STC10 - 3


R STC10 - 4

Code List Qualifier Code 65 Health Care Claim Status Code

60 1 3


60 * *

R STC11 -1

Industry Code Third Status Code 60 1 30

R STC11 - 2


S STC11 - 3


R STC11 -4


62 1 3

N STC12 Free-Form Message Text 59 1 264

2200B S INFORMATION RECEIVER SUBMISSION ACKNOWLEDGEMENT TOTAL ACCEPTED QUANTITY

R QTY01 Quantity Qualifier 90 Acknowledged Quantity

63 2 2



R QTY02 Quantity 64 1 15 Total number of good claims N QTY03 COMPOSITE UNIT OF

MEASURE 64

N QTY04 Free-Form Message Text 64 1 30

2200B S INFORMATION RECEIVER SUBMISSION ACKNOWLEDGEMENT TOTAL REJECTED QUANTITY

R QTY01 Quantity Qualifier AA Unacknowledged Quantity

66 2 2

R QTY02 Quantity 66 1 15 Total number of bad claims N QTY03 COMPOSITE UNIT OF

MEASURE 66


2200B R INFORMATION RECEIVER SUBMISSION ACKNOWLEDGEMENT TOTAL ACCEPT AMOUNT R AMT01 Amount Quantity Qualifier YU In Process 67 2 2

R AMT02 Monetary Amount 68 1 18 Sum of 837 2300 clm02 of good claims.

N AMT03 Credit/Debit Flag Code 68 1 1

2200B R INFORMATION RECEIVER SUBMISSION ACKNOWLEDGEMENT TOTAL REJECTED AMOUNT R AMT01 Amount Quantity Qualifier YY Returned 70 2 2

R AMT02 Monetary Amount 70 1 18 Sum of 837 2300 clm02 of bad claims.


2000C S BILLING/PAY-TO-PROVIDER OF SERVICE LEVEL

R HL01 Hierarchical ID Number 72 1 12 R HL02 Hierarchical Parent ID

Number 72 1 12

R HL03 Hierarchical Level Code 19 Provider of Service 72 1 2 R HL04 Hierarchical Child Code 1 Additional

Subordinate HL Data Segment in this Hierarchical Structure

72 1 1

2100C R BILLING PROVIDER NAME R NM101 Provider Entity ID Code 85 Billing Provider 74 2 3

R NM102 Provider Entity Type Qualifier

1 Person 2 Non-Person Entity

74 1 1 If 837 2010AB NM102 is empty set NM102 = 837 2010AA NM102else set NM102 = 837 2010AB NM102

R NM103 Provider Last or Organization Name

74 1 60 If NM102 = 837 2010AA NM102 NM103 = 837 2010AA NM103 else NM103 = 837 2010AB NM103



S NM104 Provider First Name 75 1 35 If NM102 = 837 2010AA NM102 NM104 = 837 2010AA NM104 else NM104 = 837 2010AB NM104

S NM105 Provider Middle Name 75 1 25 If NM102 = 837 2010AA NM102 NM105 = 837 2010AA NM105 else NM105 = 837 2010AB NM105

S NM106 Provider Name Prefix 75 1 10 If NM102 = 837 2010AA NM102 NM106 = 837 2010AA NM106else NM106 = 837 2010AB NM106

S NM107 Provider Name Suffix 75 1 10 If NM102 = 837 2010AA NM102 NM107 = 837 2010AA NM107 else NM107 = 837 2010AB NM107

R NM108 Provider Identification Code Qualifier

24 Employer's Identification Number 34 Social Security Number


R NM109 Provider Identification Code


N NM110 Entity Relationship Code

76 2 2

N NM111 Entity Identifier Code

76 2 3


76 1 60

2200C R PROVIDER OF SERVICE INFORMATION TRACE IDENTIFIER

R TRN01 Trace Type Code 1 Current Transaction Trace Numbers

77 1 2

R TRN02 Reference Identification 0 77 1 50 N TRN03 Originating Company

Identifier 78 # 10

N TRN04 Reference Identification 78 1 50

2200C R BILLING PROVIDER STATUS INFORMATION


79 * *



R STC01 - 1


R STC01 - 2

Status Code 19 Good 81 1 30

S STC01 - 3


R STC01 -4


81 1 3

N STC02 Date 82 8 8 R STC03 Action Code WQ Accept 82 1 2 R STC04 Monetary Amount 82 1 18 Sum of 837 2300 clm02 of each HL. N STC05 Monetary Amount 82 1 18 N STC06 Date 82 8 8 N STC07 Payment Method Code 82 3 3 N STC08 Date 82 8 8 N STC09 Check Number 82 1 16 S STC10 HEALTH CARE CLAIM

STATUS 83 * *

R STC10 -1


R STC10 -2


S STC10 - 3


R STC10 - 4


84 1 3


84 * *

R STC11 -1

Industry Code Third Status Code 85 1 30

R STC11 - 2


S STC11 - 3


R STC11 -4


86 1 3

N STC12 Free-Form Message Text 86 1 264

2200C S PROVIDER SECONDARY IDENTIFIER R REF01 Reference Identification

Qualifier 87 2 3

R REF02 Reference Identification

87 1 50 Get the vendor no from tblHostClaim table.

N REF03 Description 87 1 80 N REF04 REFERENCE

IDENTIFIER 87 * *



2200C S TOTAL ACCEPTED QUANTITY R QTY01 Quantity Qualifier QA Quantity

Approved 89 2 2

R QTY02 Quantity 90 1 15 Total number of good claims. N QTY03 COMPOSITE UNIT OF

MEASURE 90


2200C S TOTAL REJECTED QUANTITY R QTY01 Quantity Qualifier QC Quantity

Disapproved 91 2 2

R QTY02 Quantity 92 1 15 Total number of bad claims. N QTY03 COMPOSITE UNIT OF

MEASURE 92


2200C S TOTAL ACCEPT AMOUNT R AMT01 Amount Quantity Qualifier YU In Process 93 2 2

R AMT02 Monetary Amount 93 1 18 Sum of 837 clm02 of good claims of each HL.


2200C S TOTAL REJECTED AMOUNT R AMT01 Amount Quantity Qualifier YY Returned 94 2 2

R AMT02 Monetary Amount 94 1 18 Sum of 837 clm02 of bad claims of each HL.


2000D S PATIENT LEVEL R HL01 Hierarchical ID Number 96 1 12 R HL02 Hierarchical Parent ID

Number 96 1 12

R HL03 Hierarchical Level Code PT Patient 96 1 2 R HL04 Hierarchical Child Code 0 No Subordinate HL

Segment in this Hierarchical Structure

96 1 1

2100D R PATIENT NAME

R NM101 Subscriber Entity ID Code QC Patient 98 2 3

R NM102 Subscriber Entity Type Qualifier

1 Person 98 1 1

R NM103 Subscriber Last Name 98 1 60 If 837 2010CA NM103 is empty set NM103 =837 2010BA NM103 else set NM103 = 837 2010CA NM103



R NM104 Subscriber First Name 98 1 35 If NM103 = 837 2010BA NM103 NM104 =837 2010BA NM104 else NM104 = 837 2010CA NM104

S NM105 Subscriber Middle Name 98 1 25 If NM103 = 837 2010BA NM103 NM105 =837 2010BA NM105 else NM105 = 837 2010CA NM105

N NM106 Subscriber Name Prefix 98 1 10

S NM107 Subscriber Name Suffix 98 1 10 If NM103 = 837 2010BA NM103 NM107 =837 2010BA NM107 else NM107 = 837 2010CA NM107

R NM108 Subscriber Identification Code Qualifier

MI Member ID Number

99 1 2

R NM109 Subscriber Identification Code

99 2 80 If NM103 = 837 2010BA NM103 NM109 =837 2010BA NM109 else NM109 = 837 2010CA NM109




99 1 60

2200D R PATIENT ACCOUNT NUMBER R TRN01 Trace Type Code 2 Referenced

Transaction Trace Numbers

100 1 2

R TRN02 Reference Identification/Trace Number

101 1 50

N TRN03 Originating Company Identifier

101 # 10

S TRN04 Reference Identification 101 1 30

2200D S CLAIM LEVEL STATUS INFORMATION


103 * *

R STC01 - 1




R STC01 - 2

Status Code 19 103 1 30

S STC01 - 3


R STC01-4


104 1 3

R STC02 Date System Date 104 8 8 R STC03 Action Code WQ Accepted 104 1 2 R STC04 Total Claim Charge

Amount 105 1 18

N STC05 Claim Payment Amount 105 1 18 N STC06 Payment Date 105 8 8 N STC07 Payment Method Code 105 3 3 N STC08 Check Issue Date 105 8 8 N STC09 Check Number 105 1 16 S STC010 HEALTH CARE CLAIM

STATUS 105 * *

R STC10 -1


R STC10 -2


S STC10 - 3


R STC10 -4


106 1 3


106 * *

R STC11 -1


R STC11 - 2


S STC11 - 3


R STC11-4


107 1 3

S STC12 Free-Form Message Text 107 1 264

2200D S INFORMATION SOURCE CONTROL IDENTIFICATION NUMBER


Qualifier 1K Payer's Claim Number

109 2 3


109 1 50


IDENTIFIER 109 * *

2200D S CLAIM IDENTIFIER NUMBER FOR CLEARINGHOUSE AND OTHER TRANSMISSION INTERMEDIARIES



R REF01 Reference Identification Qualifier

D9 Claim Number 110 2 3 If 837 2300 REF01 = D9 REF01 = D9


111 1 50 If 837 2300 REF01 = D9 REF02 = 837 2300 REF02


IDENTIFIER 111 * *

2200D S INSTITUITUIONAL BILL TYPE IDENTIFICATION R REF01 Reference Identification

Qualifier BLT Billing Type 112 2 3

R REF02 Reference Identification Bill Type Identifier 113 1 50 The first two characters of the 837I 2300 clm05_01and the third character of the 837I 2300 clm05_03.


IDENTIFIER 113 * *

2200D S CLAIM LEVEL SERVICE DATE R DTP01 Claim Date/Time Qualifier 232 Claim Stetement

Period Start 114 3 3

R DTP02 Claim Date Time Period Format Qualifier

RD8 Range of Dates Expressed om Format CCYYMMDD-CCYYMMDD

115 2 3

R DTP03 Claim Date Time Period Service period date expressed as CCYYMMDD-CCYYMMDD

115 1 35 Institutional Claims use the Statement Dates Loop 2300 DTP01=434. This date can be a single date DTP02=D8 which means the To and From date are the same or it can be a range DTP02=RD8 in which the To and From date will be listed. Professional Claims use the Service Date Loop 2400 DTP01=472. This date can be a single date DTP02=D8 which means the To and From date are the same or it can be a range DTP02=RD8 in which the To and From date will be listed.

2220D S SERVICE LINE INFORMATION



R SVC01-1

Product/Service ID Qualifier

117 2 2 For Institutional:If 837I 2400 SV202-02 is empty SVC01-1 = "NU"Else SVC01-1 = 837I 2400 SV202-01

R SVC01-2

Product/Service ID 117 1 48 For Institutional: If 837I 2400 SV202-02 is empty SVC01-2 = 837I 2400 SV202-04 Else SVC01-2 = 837I 2400 SV202-02

S SVC01-3

Procedure Modifier 117 2 2

S SVC01-4


S SVC01-5


S SVC01-6


N SVC01-7

Description 118 1 80

R SVC02 Service Line Monetary Amount

118 1 18

N SVC03 Service Line Monetary Amount

118 1 18

S SVC04 Service Line Product/Service ID

118 1 48

N SVC05 Service Line Quantity 118 1 15

N SVC06 Service Line Composite Medical Procedure Identifier

118

S SVC07 Service Line Quantity 118 1 15

2220D S SERVICE LINE LEVEL STATUS INFORMATION

R STC01 - 1

Category Code A3 - Bad 120 1 30

R STC01-2

Status Code 121 1 30

S STC01

-3 Entity Identifier Code 121 2 3



R STC01

-4 Code List Qualifier Code 65 Health Care Claim

Status Code 121 1 3

N STC02 Date 121 8 8

R STC03 Action Code U Reject 121 1 2

N STC04 Total Claim Charge

Amount Line Charge Amount 121 1 18

N STC05 Claim Payment Amount 121 1 18

N STC06 Payment Date 121 8 8

N STC07 Payment Method Code 121 3 3

N STC08 Check Issue Date 121 8 8 N STC09 Check Number 121 1 16

S STC10 HEALTH CARE CLAIM

STATUS 121 * *

R STC10

-1 Industry Code Second Claim Status

Cat Code 122 1 30

R STC10 -2


S STC10

- 3 Entity Identifier Code 122 2 3

R STC10


Status Code 122 1 3

S STC11 HEALTH CARE CLAIM

STATUS 122 * *

R STC11

-1 Industry Code 122 1 30

R STC11

- 2 Industry Code 122 1 30

S STC11

- 3 Entity Identifier Code 123 2 3

R STC10


Status Code 122 1 3

S STC12 Free-Form Message Text 123 1 264

2220D S SERVICE LINE ITEM IDENTIFICATION R REF01 Reference Identification

Qualifier FJ Line Item Control Number

124 2 3

R REF02 Line Item Control Number Provider submitted line ID Number

124 1 30


IDENTIFIER 125 * *



2220D S SERVICE LINE DATE

R DTP01 Service Line Date/Time Qualifier

472 Service 126 3 3

R DTP02 Date Time Period Format Qualifier

RD8 Range of Dates expressed in format CCYYMMDD - CCYYMMDD

127 2 3

R DTP03 Service Line Date Time Period

127 1 35

R TRANSACTION SET TRAILER R SE01 Transaction Segment

Count 128 1 10

R SE02 Transaction Set Control Number

128 4 9

R FUNCTIONAL GROUP TRAILER R GE01 Number of Transactions

Sent B10 1 6

R GE02 Group Control No. B10 1 9

R INTERCHANGE CONTROL TRAILER R IEA01 Number of Functional

Groups B7 1 5

R IEA02 Interchange Control No. B7 9 9

Healthcare Claim Acknowledgement

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Transcript of Healthcare Claim Acknowledgement