Initial Instructions - wpc-edi.com Instructions ... Permission is hereby granted to any organization...

Initial Instructions

This PDF contains the initialinstructions on how to construct thebeginning of 005010X291 and005010X292 from other publishedTR3s.

From: Betsy Clore [mailto:[email protected]] Sent: Thursday, May 28, 2009 2:01 PM To: Steve Bass Cc: Tom Drinkard Subject: RE: Question about load into OnlyConnect Steve, It would be great if you could make the following changes to x291 – professional predetermination in OnlyConnect. If you can’t get them all done, I can always make comments in OnlyConnect later. Remove Loop 2010AC – Pay-To Plan NameRemove Loop 2320 – Other Subscriber InformationRemove all the 2330x Loops – 2330A Other Subscriber Information through 2330G – Other Payer Billing ProviderRemove Loop 2430 – Line Adjudication InformationDelete Segment AMT-Patient Amount Paid from Loop 2300 Thanks,Betsy CloreWake Forest University Health SciencesWFU Physicians Information SystemsMedical Center Blvd.Winston-Salem, NC 27157(336)716-0344

From: Steve Bass [mailto:[email protected]] Sent: Thursday, May 28, 2009 1:15 PM To: Betsy Clore Cc: Tom Drinkard Subject: RE: Question about load into OnlyConnect Betsy, The revised predetermination TR3 is now in OnlyConnect. We still have some time tomorrow to make other revisions, so if you have a chance, take a look at it and let me know. --Steve

From: Betsy Clore [mailto:[email protected]] Sent: Wednesday, May 27, 2009 5:37 AM To: Steve Bass Cc: Tom Drinkard Subject: RE: Question about load into OnlyConnect

Steve, Thank you so much! I think that the institutional guide front matter and professional front matter are pretty similar, so using the institutional for a base is not a problem. I will compare to the professional claim front matter and mark any additional changes in OnlyConnect to the professional predetermination. I can see how our instructions could be taken two ways. What we had really intended was to use the professional 5010 claim guide as the base for the professional predetermination guide and apply the changes as marked in the institutional to that base. I think replacing these two sections will get us pretty close so that I can make the rest of the changes in OnlyConnect. Thank you, Betsy CloreWake Forest University Health SciencesWFU Physicians Information SystemsMedical Center Blvd.Winston-Salem, NC 27157(336)716-0344

From: Steve Bass [mailto:[email protected]] Sent: Tuesday, May 26, 2009 6:57 PM To: Betsy Clore Cc: Tom Drinkard Subject: RE: Question about load into OnlyConnect Betsy, We will do whatever you need. We will start doing this tomorrow:

1. Replace Section 2.3.1 from the professional claim 5010 x222.2. Replace the entire Segment Detail section using x222 as the source.

There is an audit trail of sorts composed of several emails below and the two attachments. Email 1 from 2/26 Steve,Hope all is well.Attached is the markup of the 5010 Institutional Claim Guide.Please use this guide as a model in adding the new 005010X292 guide to OnlyConnect.

Our plan is to obtain Workgroup approval of this guide in time to start a 30-day comment period on March 30, 2009.That would allow us to hold our Informational Forum during the June Trimester meeting. Betsy Clore has asked that you use this Institutional Guide as a model for the 5010 Professional Predetermination guide (005010X291).One difference is that Betsy has asked to keep all of the DTP segments. Please let me know if you have any questions/comments. Tom Email 2 from 2/27 Rats!One of the changes in the marked-up guide I previously sent applies to Section 1.3, which is mostly Common Content. For section 1.3.1, please state that “This implementation guide IS intended …” for both batch and real-time.In section 1.3.2, please state that “There ARE other usage limitations.” Section 1.3.2 should contain the following additional sentence.“When a predetermination request is processed in real-time, only one CLM per ISA/IEA may be submitted and must be responded to in a single communication session.” Tom Email 3 from 3/3 Steve, Attached is the marked-up .pdf for just the example section of the 5010 professional predetermination guide. I left in the service dates for the drug examples that showed duration, just in case we need to keep that particular situation. I am hoping that someone will know more about this type of billing and help us with that. Let me know if you have any questions or need anything else. Thanks, Betsy CloreWake Forest University Health SciencesWFU Physicians Information SystemsMedical Center Blvd.

Winston-Salem, NC 27157(336)716-0344 Email 4 from 3/16 Steve, There is no longer any need to rush with the predetermination guide for the 837 P. Tom and I do not think that we can get the guides ready in time for approval by the workgroup on March 26th. Our “day” jobs will require most of our time for at least the rest of March. In addition, it was asking a lot of the workgroup to complete their review of the ARM and these guides within the next couple of weeks. Pete and Cathy, There will not be a need for an Informational Forum at the June meeting for the predetermination guides. Hopefully this extra time will help everyone give the attention needed to produce a good standard. --Steve

From: Betsy Clore [mailto:[email protected]] Sent: Tuesday, May 26, 2009 2:19 PM To: Betsy Clore; Steve Bass Cc: Tom Drinkard Subject: RE: Question about load into OnlyConnect Steve, First of all, I apologize for not looking closely at the professional predetermination guide in OnlyConnect sooner. I need your help. The entire Section 2.3.1 for the professional predetermination x291 needs to be replaced with the Section 2.3.1 from the professional claim 5010 x222. Currently it has the institutional transaction listing, which is very different from the professional. I don’t see any way to make that comment in OnlyConnect. Also, the entire Loop 2300 in the segment Detail needs to be taken from x222. Right now, it reflects the institutional claim. I haven’t checked the detail in the higher levels. I think it may be

safer to just replace the entire Segment Detail section using x222 as the source. I can then just mark what needs to be changed. Is this possible? Thanks,Betsy CloreWake Forest University Health SciencesWFU Physicians Information SystemsMedical Center Blvd.Winston-Salem, NC 27157(336)716-0344

From: Betsy Clore Sent: Tuesday, May 26, 2009 4:10 PM To: [email protected] Cc: Tom Drinkard Subject: Question about load into OnlyConnect Steve, Do I remember correctly that you said there was an audit trail of the changes from the base guide when you loaded the predetermination guides into OnlyConnect? If so, could we get a copy? The reason I am asking is that I am finding in the professional guide instances of “institutional” where it should say “professional” in sections that were not otherwise changed. I know that we asked you to base the professional changes on the institutional pdf markup, so that is understandable. I am just trying to determine whether I need to compare the entire guide to the 5010 professional to find any other changes where the professional may not have matched the institutional, or whether the audit trail would show those. Thanks, Betsy CloreWake Forest University Health SciencesWFU Physicians Information SystemsMedical Center Blvd.Winston-Salem, NC 27157(336)716-0344

ASC X12N/005010X223Based on Version 5, Release 1

ASC X12 Standards for Electronic Data InterchangeTechnical Report Type 3

Health Care Claim:Institutional (837)

MAY 2006

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Predetermination

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005010X292

WPC © 2006Copyright for the members of ASC X12N by Washington Publishing Company.Permission is hereby granted to any organization to copy and distribute this material internally as long as this copy-right statement is included, the contents are not changed, and the copies are not sold.

Contact Washington Publishing Company for more Information.

www.wpc-edi.com

005010X223 • 837 ASC X12N • INSURANCE SUBCOMMITTEEHEALTH CARE CLAIM: INSTITUTIONAL TECHNICAL REPORT • TYPE 3

ii MAY 2006

Table of Contents1 Purpose and Business Information............................... 1

1.1 Implementation Purpose and Scope......................................... 1

1.2 Version Information ........................................................................ 1

1.3 Implementation Limitations .......................................................... 21.3.1 Batch and Real-time Usage..................................................... 21.3.2 Other Usage Limitations ......................................................... 2

1.4 Business Usage................................................................................. 21.4.1 Coordination of Benefits ......................................................... 3

1.4.1.1 Coordination of Benefits Data Models — Detail ....... 41.4.1.2 Crosswalking COB Data Elements........................... 71.4.1.3 Coordination of Benefits Claims from Paper or

Proprietary Remittance Advices ............................. 171.4.1.4 Coordination of Benefits - Service Line

Procedure Code Bundling and Unbundling ............ 191.4.1.5 Coordination of Benefits - Medicaid

Subrogation ............................................................ 261.4.2 Property and Casualty ........................................................... 261.4.3 Data Overview ........................................................................ 26

1.4.3.1 Loop Labeling, Sequence, and Use ....................... 271.4.3.2 Data Use by Business Use..................................... 27

1.4.3.2.1 Table 1 — Transaction ControlInformation ............................................ 28

1.4.3.2.2 Table 2 — Detail Information ................. 291.4.4 Balancing ................................................................................ 34

1.4.4.1 Claim Level ............................................................. 341.4.4.2 Service Line............................................................ 35

1.4.5 Allowed/Approved Amount Calculation............................... 36

1.5 Business Terminology .................................................................. 36

1.6 Transaction Acknowledgments................................................. 391.6.1 997 Functional Acknowledgment ......................................... 391.6.2 999 Implementation Acknowledgment................................. 391.6.3 824 Application Advice .......................................................... 391.6.4 277 Health Care Claim Acknowledgment............................. 40

1.7 Related Transactions..................................................................... 401.7.1 Health Care Claim Payment/Advice (835) ............................ 40

1.8 Trading Partner Agreements ...................................................... 40

1.9 HIPAA Role in Implementation Guides................................... 41

1.10 National Provider Identifier Usage within the HIPAA 837Transaction ........................................................................................ 41

1.10.1 Providers who are Not Eligible for Enumeration ................ 411.10.2 Implementation Migration Strategy ...................................... 411.10.3 Organization Health Care Provider Subpart

Representation ....................................................................... 421.10.4 Subparts and the 2010 AA - Billing Provider Name

Loop ........................................................................................ 43

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837TECHNICAL REPORT • TYPE 3 HEALTH CARE CLAIM: INSTITUTIONAL

MAY 2006 iii

1.11 Coding of Drugs in the 837 Claim ............................................ 431.11.1 Single Drug Billing ................................................................. 441.11.2 Compound Drug Billing......................................................... 44

1.12 Additional Instructions and Considerations ....................... 441.12.1 Individuals with one Legal Name ......................................... 441.12.2 Rejecting Claims Based on the Inclusion of

Situational Data ...................................................................... 441.12.3 Multiple REF Segments with the same Qualifier................. 451.12.4 Provider Tax IDs ..................................................................... 451.12.5 Claim and Line Redundant Information ............................... 451.12.6 Inpatient and Outpatient Designation .................................. 461.12.7 Trading Partner Acknowledgments ...................................... 46

2 Transaction Set........................................................................... 47

2.1 Presentation Examples................................................................. 47

2.2 Implementation Usage .................................................................. 522.2.1 Industry Usage ....................................................................... 52

2.2.1.1 Transaction Compliance Related to IndustryUsage ..................................................................... 53

2.2.2 Loops ...................................................................................... 53

2.3 Transaction Set Listing................................................................. 552.3.1 Implementation ...................................................................... 552.3.2 X12 Standard .......................................................................... 61

2.4 837 Segment Detail......................................................................... 66ST Transaction Set Header.......................................... 67

BHT Beginning of Hierarchical Transaction .................... 68NM1 Submitter Name...................................................... 71PER Submitter EDI Contact Information......................... 73NM1 Receiver Name....................................................... 76

HL Billing Provider Hierarchical Level .......................... 78PRV Billing Provider Specialty Information ..................... 80CUR Foreign Currency Information................................. 81NM1 Billing Provider Name ............................................. 84

N3 Billing Provider Address.......................................... 87N4 Billing Provider City, State, ZIP Code ..................... 88

REF Billing Provider Tax Identification ............................ 90PER Billing Provider Contact Information ....................... 91NM1 Pay-to Address Name............................................. 94

N3 Pay-to Address - ADDRESS................................... 96N4 Pay-To Address City, State, ZIP Code .................... 97

NM1 Pay-To Plan Name.................................................. 99N3 Pay-to Plan Address ............................................. 101N4 Pay-To Plan City, State, ZIP Code........................ 102

REF Pay-to Plan Secondary Identification.................... 104REF Pay-To Plan Tax Identification Number................. 106

HL Subscriber Hierarchical Level ............................... 107SBR Subscriber Information ......................................... 109NM1 Subscriber Name.................................................. 112

N3 Subscriber Address .............................................. 115N4 Subscriber City, State, ZIP Code .......................... 116


iv MAY 2006

DMG Subscriber Demographic Information ................... 118REF Subscriber Secondary Identification ..................... 120REF Property and Casualty Claim Number .................. 121NM1 Payer Name.......................................................... 122

N3 Payer Address ...................................................... 124N4 Payer City, State, ZIP Code.................................. 125

REF Payer Secondary Identification............................. 127REF Billing Provider Secondary Identification .............. 129

HL Patient Hierarchical Level ..................................... 131PAT Patient Information ............................................... 133

NM1 Patient Name........................................................ 135N3 Patient Address .................................................... 137N4 Patient City, State, ZIP Code ................................ 138

DMG Patient Demographic Information ......................... 140REF Property and Casualty Claim Number .................. 142CLM Claim Information ................................................. 143DTP Discharge Hour..................................................... 149DTP Statement Dates................................................... 150DTP Admission Date/Hour............................................ 151DTP Date - Repricer Received Date............................. 152CL1 Institutional Claim Code........................................ 153

PWK Claim Supplemental Information........................... 154CN1 Contract Information ............................................. 158AMT Patient Estimated Amount Due............................. 160REF Service Authorization Exception Code ................. 161REF Referral Number ................................................... 163REF Prior Authorization ................................................ 164REF Payer Claim Control Number................................ 166REF Repriced Claim Number ....................................... 167REF Adjusted Repriced Claim Number ........................ 168REF Investigational Device Exemption Number........... 169REF Claim Identifier For Transmission

Intermediaries....................................................... 170REF Auto Accident State .............................................. 172REF Medical Record Number....................................... 173REF Demonstration Project Identifier ........................... 174REF Peer Review Organization (PRO) Approval

Number................................................................. 175K3 File Information..................................................... 176

NTE Claim Note............................................................ 178NTE Billing Note ........................................................... 180CRC EPSDT Referral .................................................... 181

HI Principal Diagnosis ............................................... 184HI Admitting Diagnosis .............................................. 187HI Patient’s Reason For Visit .................................... 189HI External Cause of Injury ....................................... 193HI Diagnosis Related Group (DRG) Information ....... 218HI Other Diagnosis Information................................. 220HI Principal Procedure Information ........................... 239HI Other Procedure Information ................................ 242HI Occurrence Span Information............................... 258HI Occurrence Information ........................................ 271HI Value Information.................................................. 284


MAY 2006 v

HI Condition Information ........................................... 294HI Treatment Code Information................................. 304

HCP Claim Pricing/Repricing Information ..................... 313NM1 Attending Provider Name ..................................... 319PRV Attending Provider Specialty Information ............. 322REF Attending Provider Secondary Identification......... 324NM1 Operating Physician Name................................... 326REF Operating Physician Secondary Identification ...... 329NM1 Other Operating Physician Name......................... 331REF Other Operating Physician Secondary

Identification ......................................................... 334NM1 Rendering Provider Name .................................... 336REF Rendering Provider Secondary Identification ....... 339NM1 Service Facility Location Name ............................ 341

N3 Service Facility Location Address......................... 344N4 Service Facility Location City, State, ZIP Code .... 345

REF Service Facility Location SecondaryIdentification ......................................................... 347

NM1 Referring Provider Name...................................... 349REF Referring Provider Secondary Identification ......... 352SBR Other Subscriber Information ............................... 354CAS Claim Level Adjustments ...................................... 358AMT Coordination of Benefits (COB) Payer Paid

Amount ................................................................. 364AMT Remaining Patient Liability ................................... 365AMT Coordination of Benefits (COB) Total

Non-Covered Amount ........................................... 366OI Other Insurance Coverage Information ................ 367

MIA Inpatient Adjudication Information......................... 369MOA Outpatient Adjudication Information...................... 374NM1 Other Subscriber Name........................................ 377

N3 Other Subscriber Address .................................... 380N4 Other Subscriber City, State, ZIP Code ................ 381

REF Other Subscriber Secondary Identification ........... 383NM1 Other Payer Name................................................ 384

N3 Other Payer Address ............................................ 386N4 Other Payer City, State, ZIP Code........................ 387

DTP Claim Check or Remittance Date ......................... 389REF Other Payer Secondary Identifier ......................... 390REF Other Payer Prior Authorization Number .............. 392REF Other Payer Referral Number............................... 393REF Other Payer Claim Adjustment Indicator .............. 394REF Other Payer Claim Control Number...................... 395NM1 Other Payer Attending Provider............................ 396REF Other Payer Attending Provider Secondary

Identification ......................................................... 398NM1 Other Payer Operating Physician ......................... 400REF Other Payer Operating Physician Secondary

Identification ......................................................... 402NM1 Other Payer Other Operating Physician ............... 404REF Other Payer Other Operating Physician

Secondary Identification ....................................... 406NM1 Other Payer Service Facility Location .................. 408


vi MAY 2006

REF Other Payer Service Facility LocationSecondary Identification ....................................... 410

NM1 Other Payer Rendering Provider Name................ 412REF Other Payer Rendering Provider Secondary

Identification ......................................................... 414NM1 Other Payer Referring Provider ............................ 416REF Other Payer Referring Provider Secondary

Identification ......................................................... 418NM1 Other Payer Billing Provider ................................. 420REF Other Payer Billing Provider Secondary

Identification ......................................................... 422LX Service Line Number ............................................ 423

SV2 Institutional Service Line....................................... 424PWK Line Supplemental Information............................. 429DTP Date - Service Date .............................................. 433REF Line Item Control Number .................................... 435REF Repriced Line Item Reference Number ................ 437REF Adjusted Repriced Line Item Reference

Number................................................................. 438AMT Service Tax Amount .............................................. 439AMT Facility Tax Amount............................................... 440NTE Third Party Organization Notes ............................ 441HCP Line Pricing/Repricing Information........................ 442

LIN Drug Identification................................................. 449CTP Drug Quantity ....................................................... 452REF Prescription or Compound Drug Association

Number................................................................. 454NM1 Operating Physician Name................................... 456REF Operating Physician Secondary Identification ...... 459NM1 Other Operating Physician Name......................... 461REF Other Operating Physician Secondary

Identification ......................................................... 464NM1 Rendering Provider Name .................................... 466REF Rendering Provider Secondary Identification ....... 469NM1 Referring Provider Name...................................... 471REF Referring Provider Secondary Identification ......... 474SVD Line Adjudication Information................................ 476CAS Line Adjustment .................................................... 480DTP Line Check or Remittance Date............................ 486AMT Remaining Patient Liability ................................... 487

SE Transaction Set Trailer.......................................... 488

3 Examples....................................................................................... 489

3.1 Institutional...................................................................................... 4893.1.1 Business Scenario 1 — 837 Institutional Claim ................ 4893.1.2 Business Scenario 2 — Two Claims for the Same

Provider ................................................................................ 4943.1.3 Business Scenario 3 — PPO Repriced Claim ................... 5003.1.4 Business Scenario 4 — Out of Network Repriced

Claim ..................................................................................... 506

3.2 Property and Casualty ................................................................ 5113.2.1 Business Scenario 1 — Automobile Accident................... 511


MAY 2006 vii

A External Code Sources ........................................................A.1

5 Countries, Currencies and Funds .......................................A.122 States and Provinces............................................................A.251 ZIP Code ................................................................................A.2

130 Healthcare Common Procedural Coding System ..............A.3131 International Classification of Diseases, 9th Revision,

Clinical Modification (ICD-9-CM) .........................................A.4132 National Uniform Billing Committee (NUBC) Codes..........A.4139 Claim Adjustment Reason Code..........................................A.5229 Diagnosis Related Group Number (DRG) ...........................A.5230 Admission Source Code ......................................................A.5231 Admission Type Code...........................................................A.6235 Claim Frequency Type Code ................................................A.6236 Uniform Billing Claim Form Bill Type..................................A.7239 Patient Status Code ..............................................................A.7240 National Drug Code by Format ............................................A.8245 National Association of Insurance Commissioners

(NAIC) Code ...........................................................................A.8359 Treatment Codes ...................................................................A.8411 Remittance Advice Remark Codes......................................A.9513 Home Infusion EDI Coalition (HIEC) Product/Service

Code List................................................................................A.9537 Centers for Medicare and Medicaid Services National

Provider Identifier ...............................................................A.10540 Centers for Medicare and Medicaid Services PlanID ......A.10576 Workers Compensation Specific Procedure and

Supply Codes ...................................................................... A.11682 Health Care Provider Taxonomy........................................A.12716 Health Insurance Prospective Payment System

(HIPPS) Rate Code for Skilled Nursing Facilities.............A.12843 Advanced Billing Concepts (ABC) Codes ........................A.13896 International Classification of Diseases, 10th

Revision, Procedure Coding System (ICD-10-PCS).........A.13897 International Classification of Diseases, 10th

Revision, Clinical Modification (ICD-10-CM) ....................A.14932 Universal Postal Codes ......................................................A.14

B Nomenclature..............................................................................B.1

B.1 ASC X12 Nomenclature ...............................................................B.1B.1.1 Interchange and Application Control Structures ...............B.1

B.1.1.1 Interchange Control Structure ...............................B.1B.1.1.2 Application Control Structure Definitions and

Concepts ...............................................................B.2B.1.1.3 Business Transaction Structure Definitions and

Concepts ...............................................................B.6B.1.1.4 Envelopes and Control Structures.......................B.19B.1.1.5 Acknowledgments ...............................................B.22

B.2 Object Descriptors.......................................................................B.23


viii MAY 2006

C EDI Control Directory ............................................................C.1

C.1 Control Segments ..........................................................................C.1ISA Interchange Control Header.................................................C.3GS Functional Group Header .....................................................C.7GE Functional Group Trailer ......................................................C.9IEA Interchange Control Trailer ................................................C.10

D Change Summary ....................................................................D.1

D.1 Global Changes ..............................................................................D.1

D.2 Detailed Transaction Changes .................................................D.2

E Data Element Glossary ........................................................E.1

E.1 Data Element Name Index ..........................................................E.1


MAY 2006 ix


x MAY 2006

1 Purpose and Business Information

1.1 Implementation Purpose and ScopeFor the health care industry to achieve the potential administrative cost savings withElectronic Data Interchange (EDI), standards have been developed and need to beimplemented consistently by all organizations. To facilitate a smooth transition into theEDI environment, uniform implementation is critical.

This is the technical report document for the ANSI ASC X12N 837 Health Care Claims(837) transaction for institutional claims and/or encounters. This document provides adefinitive statement of what trading partners must be able to support in this version ofthe 837. This document is intended to be compliant with the data standards set out bythe Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its associatedrules.

1.2 Version InformationThis implementation guide is based on the October 2003 ASC X12 standards, referredto as Version 5, Release 1, Sub-release 0 (005010).

The unique Version/Release/Industry Identifier Code for transaction sets that are definedby this implementation guide is 005010X223.

The two-character Functional Identifier Code for the transaction set included in thisimplementation guide:

• HC Health Care Claim (837)

The Version/Release/Industry Identifier Code and the applicable Functional IdentifierCode must be transmitted in the Functional Group Header (GS segment) that begins afunctional group of these transaction sets. For more information, see the descriptionsof GS01 and GS08 in Appendix C, EDI Control Directory.

1MAY 2006

005010X223 • 837HEALTH CARE CLAIM: INSTITUTIONAL

ASC X12N • INSURANCE SUBCOMMITTEETECHNICAL REPORT • TYPE 3

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predeterminations or estimates. This technical report will use the terms "predetermination" and "estimate" interchangeably. See Section 1.5 Business Terminology for definitions.

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005010X292.

1.3 Implementation Limitations

1.3.1 Batch and Real-time UsageThere are multiple methods available for sending and receiving business transactionselectronically. Two common modes for EDI transactions are batch and real-time.

Batch - In a batch mode the sender does not remain connected while the receiverprocesses the transactions. Processing is usually completed according to a set schedule.If there is an associated business response transaction (such as a 271 Response to a270 Request for Eligibility), the receiver creates the response transaction and stores itfor future delivery.The sender of the original transmission reconnects at a later time andpicks up the response transaction. This implementation guide does not set specificresponse time parameters for these activities.

Real Time - In real-time mode the sender remains connected while the receiver processesthe transactions and returns a response transaction to the sender. This implementationguide does not set specific response time parameters for implementers.

This implementation guide is intended to support use in batch mode.This implementationguide is not intended to support use in real-time mode. A statement that the transactionis not intended to support a specific mode does not preclude its use in that mode betweenwilling trading partners.

1.3.2 Other Usage LimitationsReceiving trading partners may have system limitations which control the size of thetransmission they can receive. Some submitters may have the capability and the desireto transmit large 837 transactions with thousands of claims contained in them. Thedevelopers of this implementation guide recommend that trading partners limit the sizeof the transaction (ST-SE envelope) to a maximum of 5000 CLM segments. Willingtrading partners can agree to higher limits.There is no recommended limit to the numberof ST-SE transactions within a GS-GE or ISA-IEA.

1.4 Business UsageThis transaction set can be used to submit health care claim billing information, encounterinformation, or both, from providers of health care services to payers, either directly orvia intermediary billing services and claims clearinghouses. It can also be used to transmithealth care claims and billing payment information between payers with different payment

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when submitted in batch mode.

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When a predetermination request is processed in real-time, only one CLM per ISA/IEA may be submitted and must be responded to in a single communication session.

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Replace this paragraph with: "This implementation guide is intended to support both batch and real-time submission of health care predetermination requests.".

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Replace the first paragraph in Section 1.4 Business Usage with the following:" This transaction set can be used to submit health care predetermination requests from providers of health care services to payers, either directly or via intermediary billing services and claims clearinghouses."

responsibilities where coordination of benefits (COB) is required or between payers andregulatory agencies to monitor the rendering, billing, and/or payment of health careservices within a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may includeentities such as physicians, dentists, hospitals, pharmacies, other medical facilities orsuppliers, and entities providing medical information to meet regulatory requirements.The payer is a third party entity that pays claims or administers the insurance productor benefit or both. For example, a payer may be an insurance company, healthmaintenance organization (HMO), preferred provider organization (PPO), governmentagency (Medicare, Medicaid, TRICARE, etc.) or an entity such as a third partyadministrator (TPA), repricer, or third party organization (TPO) that may be contractedby one of those groups. A regulatory agency is an entity responsible, by law or rule, foradministering and monitoring a statutory benefits program or a specific segment of thehealth care/insurance industry.

The transaction defined by this implementation guide is intended to originate with thehealth care provider or the health care provider’s designated agent. In some instances,a health care payer may originate an 837 to report a health care encounter to anotherpayer or sponsoring organization.The 837 Transaction provides all necessary informationto allow the destination payer to at least begin to adjudicate the claim. The 837coordinates with a variety of other transactions including, but not limited to, the following:Health Care Information Status Notification (277), Health Care Claim Payment/Advice(835) and the Functional Acknowledgment (997). See Section 1.6 - TransactionAcknowledgments, and Section 1.7 - Related Transactions, for a summary descriptionof these interactions.

1.4.1 Coordination of BenefitsA primary enhancement for this version is upgrading COB functionality to minimizemanual intervention and/or the necessity for paper supporting document. Electronic COBis predicated upon using two transactions – the 837 and the 835 Health Care ClaimPayment/Advice. See Section 1.4.1.1 - Coordination of Benefits Data Models -- Detailfor details about the two models for using these transactions to achieve a totally electronicinterchange of COB information. Section 3, EDI Transmission Examples for DifferentBusiness Uses, contains detailed examples of how these transactions are completedfor several business situations. Section 1.4.1.3 - Coordination of Benefits Claims fromPaper or Proprietary Remittance Advices provides guidance on creating electronic COBclaims when the payer’s remittance was a paper or proprietary remittance advice.

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Add the following to the end of Section 1.4: NOTE The 837 is not intended for use in exchanging referrals and certifications. Use the 278 Health Care Services Review - Request for Review and Response transaction instead.

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Remove the contents of section 1.4.1 and replace with "Not applicable to predetermination or estimate requests".

1.4.1.1 Coordination of Benefits Data Models -- DetailThe 837 Transaction handles two different models of benefit coordination. Both modelsare discussed in this section. Section 3, Examples, contains detailed examples of thesemodels. Each COB related data element contains notes within this implementation guidespecifying when it is used.The HIPAA final rules contain additional information on COB.

Model 1 -- Provider-to-Payer-to-ProviderStep 1. In model 1, the provider originates the transaction and sends the claim informationto Payer A, the primary payer. See Figure 1.1 - Provider-to-Payer-to-Provider COBModel.The Subscriber loop (Loop ID-2000B) contains information about the person whoholds the policy with Payer A. Loop ID-2320 contains information about Payer B and thesubscriber who holds the policy with Payer B. In this model, the primary payer adjudicatesthe claim and sends an electronic remittance advice (RA) transaction (835) back to theprovider.The 835 contains any claim adjustment reason codes that apply to that specificclaim. The claim adjustment reason codes detail what was adjusted and why.

Figure 1.1 - Provider-to-Payer-to-Provider COB Model

Step 2. Upon receipt of the 835, the provider sends a second health care claim transaction(837) to Payer B, the secondary payer. The Subscriber loop (Loop ID-2000B) nowcontains information about the subscriber who holds the policy with Payer B. The OtherSubscriber Information loop (Loop ID-2320) now contains information about the subscriberfor Payer A. Any total amounts paid at the claim level go in the AMT segment in LoopID-2320. Any claim level adjustment codes are retrieved from the 835 from Payer A andput in the CAS (Claims Adjustment) segment in Loop ID-2320. Line Level adjustmentreason codes are retrieved similarly from the 835 and go in the CAS segment in the2430 loop. Payer B adjudicates the claim and sends the provider an electronic remittanceadvice.

Step 3. If there are additional payers (not shown inFigure 1.1 - Provider-to-Payer-to-Provider COB Model), step 2 is repeated with the

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Subscriber loop (Loop ID-2000B) having information about the subscriber who holds thepolicy with Payer C, the tertiary payer. COB information specific to Payer A continuesto be included as written in step 2 with an occurrence of Loop ID-2320 and specifyingthe payer as primary. If necessary, Loop ID-2430 is included for any line leveladjudications. COB information specific to Payer B is included by repeating the LoopID-2320 again and specifying the payer as secondary. If necessary, Loop ID-2430 isincluded for Payer B line level adjudications.

Model 2 -- Provider-to-Payer-to-PayerStep 1. In model 2, the provider originates the transaction and sends claim informationto Payer A, the primary payer. See Figure 1.2 - Provider-to-Payer-to-Payer COB Model.The Subscriber loop (Loop ID-2000B) contains information about the person who holdsthe policy with Payer A. Subscriber/payer information about secondary coverage isincluded in Loop ID-2320 or is on file at Payer A as a result of an eligibility file sent byPayer B (as in Medicare crossover arrangements). In this model, the primary payeradjudicates the claim and sends an 835 back to the provider.

Figure 1.2 - Provider-to-Payer-to-Payer COB Model

Step 2. Payer A reformats the 837 and sends it to the secondary payer. In reformattingthe claim, Payer A takes the information about their subscriber and places it in LoopID-2320. Payer A also takes the information about Payer B, the secondarypayer/subscriber, and places it in the appropriate fields in the Subscriber Loop ID-2000B.Then Payer A sends the claim to Payer B. All COB information from Payer A is placedin the appropriate Loop ID-2320 and/or Loop ID-2430.

Step 3. Payer B receives the claim from Payer A and adjudicates the claim. Payer Bsends an 835 to the provider. If there is a tertiary payer, Payer B performs step 2 ineither Model 1 or Model 2.

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1.4.1.1.1 Coordination of Benefits -- Claim LevelThe destination payer’s information is located in Loop ID-2010BB. In addition, anydestination payer-specific claim information (for example, referral number) is located inthe 2300 loop. All provider identifiers in the 2310 loops are specific to the destinationpayer. Loop ID-2320 occurs once for each payer responsible for the claim, except forthe payer receiving the 837 transaction set (destination payer). Provider identifiers inthe 2330 loops are specific to the corresponding non-destination payer.

Loop ID-2320 contains the following:

• claim level adjustments• other subscriber demographics• various amounts• other payer information• assignment of benefits indicator• patient signature indicator

Inside Loop ID-2320, Loop ID-2330 contains the information for the payer and thesubscriber. As the claim moves from payer to payer, the destination payer’s informationin Loop ID-2000B and Loop ID-2010BB must be exchanged with the next payer’sinformation from Loop ID-2320/2330.

1.4.1.1.2 Coordination of Benefits -- Service Line LevelLoop ID-2430 is a situational loop that can occur up to 15 times for each service line.As each payer adjudicates the service lines, occurrences may be added to this loop toexplain how the payer adjudicated the service line.

Loop ID-2430 contains the following:

• ID of the payer who adjudicated the service line• amount paid for the service line• procedure code upon which adjudication of the service line was based.This code may

be different than the submitted procedure code. (This procedure code also can beused for unbundling or bundling service lines.)

• paid units of service• service line level adjustments• adjudication date

To enable accurate matching of billed service lines with paid service lines, the payermust return the original billed procedure code(s) and/or modifiers in the SVC06 andSVC07 data element of the 835 if they are different from those used to pay the line. In

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addition, if a provider includes a line item control number at the 2400 level (REF01 =6R), then payers are required to return this in any corresponding 835 regardless ofwhether bundling or unbundling has occurred.

1.4.1.2 Crosswalking COB Data ElementsThis section provides additional guidance for automation of the COB process. Thepurpose of the discussion below is to clarify how multiple payer and related COB datais structured and interrelated to facilitate an automated COB process. These strategiesapply to both payer and provider submitted COB claims.

For the purposes of this discussion, there are two types of payers in the 837; (1) thedestination payer, the payer receiving the claim and defined in the 2010BB loop, and(2) any ’other’ payers, those defined in the 2330B loop(s). The destination payer or the’other’ payers may be the primary, secondary or another position payer in terms of theirsequence of paying on the claim. The payment position is not particularly important indiscussing how to manage COB data elements in the 837. For this discussion, it is onlyimportant to distinguish between the destination payer and any other payer containedin the claim. In a COB situation each payer in the claim takes a turn at being thedestination payer. As the destination payer changes, payer information must changeposition along with the payer to stay associated with that payer. The same is true of allthe ’other’ payers, who will each, in turn, become the destination payer as the claim isforwarded to them. It is the purpose of the example detailed below to demonstrate exactlyhow payer specific information stays associated with the correct payer as the destinationpayer rotates through the various COB payers.

Business Model:The destination payer is defined as the payer that is described in the 2010BB loop. Allof the information contained in the 2300 and 2310 loops is specific to the destinationpayer. Information specific to other payers is contained in the 2320, 2330, and 2430loops. Referral, predetermination, and prior authorization numbers in the 2400 loop; andprovider numbers in the 2420 loop are associated with either the destination or anon-destination payer.

Institutional Claim 837 X223(In this crosswalk, the Subscriber is NOT the Patient, and the Original Claim isNOT a resubmission)

Primary Subscriber is JOHN DOE who has coverage with ABC INS; Secondary Subscriberis JANE DOE who has coverage with XYZ INS GROUP; Patient is daughter SALLYDOE.

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COLOR KEY

D -- Destination Payer Loops and Data - Once the primary payer has adjudicated the claim, whoever submits the claim to the secondarypayer needs to place the information specific to the secondary payer (columns 4 and 5) into the “destination payer” location (column 1)in the secondary claim.

N -- Other (non-destination) Payer Loops and Data - Once the primary payer has adjudicated the claim, whoever submits the claim to thesecondary payer needs to place the information specific to the primary payer (columns 4 and 5) into the other (non-destination) payerlocation (column 1) in the secondary claim.

M -- Medicare COB - This information is entered by Medicare on the secondary (crossover) claim in Payer-to-Payer COB elements (column4).

P -- Provider Submitted COB Data – This information is entered by the provider into the secondary claim elements (column 4) prior toforwarding to the next payer.

E -- Prior Payer 835 Data – This information is cross-walked from the 835 Remittance Advice (column 3) to elements in the secondaryclaim (column 4).

5Secondary PayerClaim Example

4CrosswalkSecondary 837Claim From Primary1

3835 ERA

2Primary PayerClaim Example

1Primary Payer837 Claim

FOR JANE DOE2320 | SBR (exceptSBR02)

FOR JOHN DOE2000B | SBRSubscriber Information

D

JANE DOEJA7654321765432111

2330A | NM1 | REFJOHN DOEJD03398777033987777

2010BA | NM1 | REFSubscriber NameSecondaryIdentification

D

Not Used2Not UsedNot Used2Not Used2

Subscriber AddressD

XYZ INS GROUP2330BABC INS2010BBPayer Information

D

FOR XYZ INS GROUP(G2) XYZ3434343

2330I | REF (2U withG2)

FOR ABC INS12345678

2010BB | REF (G2)Billing ProviderSecondary ID

D

FOR XYZ INS GROUP(LU) 455

2330I | REF (2U withLU)

FOR ABC INS678

2010BB | REF (LU)Billing ProviderLocation Code

D

SALLY’SRELATIONSHIPTO JANE –19 CHILD

2320 | SBR02SALLY’SRELATIONSHIP TOJOHN – 19 CHILD

2000C | PAT01Patient Information

D

SALLY DOE2010CA | NM1SALLY DOE2010CA | NM1Patient NameInformation

D

FOR JANE DOE2320 | OI05FOR JOHN DOE2300 | CLM07Accept AssignmentIndicator

D

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FOR JANE DOE2320 | OI03FOR JOHN DOE2300 | CLM08Assignment ofBenefits Indicator

D

FOR JANE DOE2320 | OI06FOR JOHN DOE2300 | CLM09Release ofInformation

D

FOR JANE DOE2320 | OI04FOR JOHN DOE2300 | CLM10Patient’s SignatureSource Code

D

Set by Medicare inCrossover Claims

2300 | REF01/02Not UsedN/AMedicare (Section4081)Crossover Indicator

M


2330B | REF (G1)FOR ABC INS(G1) ABC456

2300 | REF (G1)Prior Authorization

D

FOR XYZ INS GROUP(9F) XYZ6798777

2330B | REF (9F)FOR ABC INS(9F) ABC670000

2300 | REF (9F)Referral Number

D


2330C | REF (G2)FOR ABC INS(G2) ABC670001

2310A | REF (G2)Attending ProviderSecondary ID

D


2330C | REF (LU)FOR ABC INS(LU) 671

2310A | REF (LU)Attending ProviderSecondary ID

D


2330D | REF (G2)FOR ABC INS(G2) ABC670002

2310B | REF (G2)Operating PhysicianSecondary ID

D


2330D | REF (LU)FOR ABC INS(LU) 672

2310B | REF (LU)Operating PhysicianSecondary ID

D


2330E | REF (G2)FOR ABC INS(G2) ABC670004

2310C | REF (G2)Other OperatingPhysician SecondaryID

D


2330E | REF (LU)FOR ABC INS(LU) 674

2310C | REF (LU)Other OperatingPhysician SecondaryID

D


2330F | REF (G2)FOR ABC INS(G2) ABC670005

2310E | REF (G2)Service FacilityLocation Secondary ID

D


2330F | REF (LU)FOR ABC INS(LU) 675

2310E | REF (LU)Service FacilityLocation Secondary ID

D

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3835 ERA



FOR JOHN DOE2000B | SBR (exceptSBR02)

FOR JANE DOE2320 | SBR(except SBR02)Subscriber Information

N

SALLY’SRELATIONSHIPTO JOHN – 19CHILD

2000C | PAT01SALLY’SRELATIONSHIPTO JANE – 17STEPCHILD

2320 | SBR02Subscriber Relationshipto Patient

N

FROM ABC INS2320 | CAS2100 | CASNot UsedClaim AdjustmentGroup Code

E

FROM ABC INS2320 | AMT01/02 (D)2100 | CLP04Not UsedPayer Paid AmountE

FROM ABC INS2320 | AMT01/02 (A8)2100 | AMT (A8)Not UsedTotal Non-CoveredAmount

E

Calculated byProvider

2320 | AMT01 (EAF)Not UsedRemaining PatientLiability

P

Not UsedNot UsedFOR JANE DOE2320 | DMGSubscriberDemographicInformation

N

FOR JOHN DOE2300 | CLM07FOR JANE DOE2320 | OI05Accept AssignmentIndicator

N

FOR JOHN DOE2300 | CLM08FOR JANE DOE2320 | OI03Assignment ofBenefit Indicator

N

FOR JOHN DOE2300 | CLM09FOR JANE DOE2320 | OI06Release of Information

N

FOR JOHN DOE2300 | CLM10FOR JANE DOE2320 | OI04Patient’s SignatureSource Code

N

FROM ABC INS2320 | MOA2100 | MOANot UsedMedicare OutpatientAdjudicationInformation

E

JOHN DOEJD03398777033987777

2010BA | NM1 | REFJANE DOEJA7654321765432111

2330A | NM1 | REFSubscriber NameSecondary ID

N

FOR JOHN DOE2010BA | N3/N4FOR JANE DOE2330A | N3/N4Subscriber Address

N

FOR JOHN DOE2010BBFOR XYZ INS GROUP2330BPayer Information

N

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FOR ABC INSNot Used FOR XYZ INS GROUP2330B | PERPayer ContactInformation

N

FROM ABC INS2330B | DTP (573)Table 1 | BPR16Not UsedClaim AdjudicationDate

E

FROM ABC INSXYZCLM0005

2330B | REF (F8)2100 | CLP073Not UsedPayer Claim ControlSecondary Number

N

FOR ABC INSABC456

2300 | REF (G1)FOR XYZ INS GROUPXYZ345200

2330B | REF (G1)Prior Authorization

N

FOR ABC INSABC670000

2300 | REF (9F)FOR XYZ INS GROUPXYZ6798777

2330B | REF (9F)Referral Number

N

FOR ABC INS(G2) ABC670001

2310A | REF (G2)FOR XYZ INS GROUP(G2) XYZ6798666

2330C | REF (G2)Attending ProviderSecondary ID

N

FOR ABC INS(LU) 671

2310A | REF (LU)FOR XYZ INS GROUP(LU) 986

2330C | REF (LU)Attending ProviderSecondary ID

N


2310B | REF (G2)FOR XYZ INS GROUP(G2) XYZ6798444

2330D | REF (G2)Operating PhysicianSecondary ID

N

FOR ABC INS(LU) 672

2310B | REF (LU)FOR XYZ INS GROUP(LU) 984

2330D | REF (LU)Operating PhysicianSecondary ID

N


2310C | REF (G2)FOR XYZ INS GROUP(G2) XYZ6798222

2330E | REF (G2)Other OperatingPhysicianSecondary ID

N

FOR ABC INS(LU) 674

2310C | REF (LU)FOR XYZ INS GROUP(LU) 982

2330E | REF (LU)Other OperatingPhysicianSecondary ID

N


2310E | REF (G2)FOR XYZ INS GROUP(G2) XYZ6798111

2330F | REF (G2)Service FacilityLocation Secondary ID

N

FOR ABC INS(LU) 675

2310E | REF (LU)FOR XYZ INS GROUP(LU) 981

2330F | REF (LU)Service FacilityLocation Secondary ID

N

FOR ABC INS(G2) 12345678

2010BB | REF (G2)FOR XYZ INS GROUP(G2) XYZ3434343

2330I | REF (G2)Billing Provider ID

N

FOR ABC INS(LU) 678

2010BB | REF (LU)FOR XYZ INS GROUP(LU) 455

2330I | REF (LU)Billing Provider ID

N

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2400 | REF (G1/2U)FOR ABC INS(G1) ABC222222

2400 | REF (G1)Prior AuthorizationNumber

D

FOR ABC INS(G1) ABC222222(2U) 12345

2400 | REF (G1)FOR XYZ INS GROUP(G1) XYZ888888(2U) 54698

2400 | REF (G1/2U)Prior AuthorizationNumber

N

FOR XYZ INS GROUP(9F) XYZ777777

2400 | REF (9F/2U)FOR ABC INS(9F) ABC111111

2400 | REF (9F)Referral Number

D

FOR ABC INS(9F) ABC111111(2U) 12345

2400 | REF (9F)FOR XYZ INS GROUP(9F) XYZ777777(2U) 54698

2400 | REF (9F/2U)Referral Number

N


2420A | REF (G2/2U)4FOR ABC INS(G2) ABC888888

2420A | REF (G2)4

Operating PhysicianSecondary ID

D

FOR XYZ INS GROUP(LU) Z666

2420A | REF (LU/2U)4FOR ABC INS(LU) C333

2420A | REF (LU)4


D


2420A | REF (G2)4FOR XYZ INS GROUP(G2) XYZ666666(2U)54698

2420A | REF (G2/2U)4


N

FOR ABC INS(LU) C333(2U) 12345

2420A | REF (LU)4FOR XYZ INS GROUP(LU) Z666(2U) 54698

2420A | REF (LU/2U)4


N


2420B | REF (G2/2U)4FOR ABC INS(G2) ABC444444

2420B | REF (G2)4

Other OperatingPhysicianSecondary ID

D


2420B | REF (LU/2U)4FOR ABC INS(LU) C444

2420B | REF (LU)4


D


2420B | REF (G2)4FOR XYZ INS GROUP(G2) XYZ555555(2U) 54698

2420B | REF (G2/2U)4


N


2420B | REF (LU)4FOR XYZ INS GROUP(LU) Z555(2U) 54698

2420B | REF (LU/2U)4


N


2420C | REF (G2/2U)4FOR ABC INS(G2) ABC555555

2420C | REF (G2)4

Rendering ProviderSecondary ID

D

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3835 ERA




2420C | REF (LU/2U)4FOR ABC INS(LU) C555

2420C | REF (LU)4


D


2420C | REF (G2)4FOR XYZ INS GROUP(G2) XYZ444444(2U) 54698

2420C | REF (G2/2U)4


N


2420C | REF (LU)4FOR XYZ INS GROUP(LU) Z444(2U) 54698

2420C | REF (LU/2U)4


N


2420F | REF (G2/2U)4FOR ABC INS(G2) ABC888888

2420D | REF (G2)4

Referring ProviderSecondary ID

D


2420F | REF (LU/2U)4FOR ABC INS(LU) C888

2420D | REF (LU)4


D


2420F | REF (G2)4FOR XYZ INS GROUP(G2) XYZ111111(2U) 54698

2420D | REF (G2/2U)4


N


2420F | REF (LU)4FOR XYZ INS GROUP(LU) Z111(2U) 54698

2420D | REF (LU/2U)4


N

FROM ABC INS2430 | SVD2200 | SVDNot UsedService LinePaid Amount

E

FROM ABC INS2430 | CAS2200 | CASNot UsedClaim AdjustmentInformation

E

FROM ABC INS2430 | DTP (573)Table 1 | BPR16Not UsedLine AdjudicationDate

E

Calculated byProvider

2430 | AMT01 (EAF)Not UsedRemaining PatientLiability Amount

P

1 The secondary claim information shows where the original claim information would be mapped to whencreating the secondary claim. This information must be in the correct order of the implementation guide andnot in the order shown above.

2 The Subscriber Address in the 2010BB Loop is only used when the Patient is the Subscriber.

3 2300REF Original Payer Claim NumberThe Original Payer Claim Number is used to submit the Claim Number returned on the 835 whenever a claimis resubmitted to the same payer. When submitting a secondary claim that was resubmitted to the first payer,this number is carried in the 2330B REF. It is important to keep a Payer Original Claim Number in the loopassociated with that payer. In the example below, the number returned by the first payer is used in the

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destination claim loop when resubmitting to that payer. Then when the secondary claim is created, the firstpayer’s Original Claim Number is moved down into the Loop ID-2330B REF for the first payer.

Secondary ClaimResubmitted ClaimRemittance AdviceOriginal Claim

Not Used2300 | REF (F8)2100 | CLP07Not Used2300 REF (F8)

2300 REF (F8)Not UsedNot Used2330B REF (F8)

4 2420A-F Provider Secondary IdentifiersThe G2 and LU Qualifiers and the Secondary Identifiers in these Loops are for both the Destination Payerand the Non-Destination Payer. The 2U Qualifier is specific to the Non-Destination Payer. When creating thesecondary claim, the numbers are swapped as follows:

Secondary ClaimOriginal Claim

5469812345Payer IDNM108/092010BB

1234554698Payer IDNM108-092330B

G2G2Rendering Provider ID FOR PayerREF012420A

XYZ666666ABC333333REF022420A

LULURendering Provider Location CodeREF012420A

Z666C333REF022420A

G2G2Rendering Provider Secondary IDREF012420A

ABC333333XYZ666666(For Non-destination Payer identified below)REF022420A

Not UsedREF032420A

2U2UOther Payer ID (linked to 2330B Payer)REF04-12420A

1234554698REF04-22420A

LULURendering Provider Location CodeREF012420A

C333Z666(For Non-destination Payer identified below)REF022420A

Not UsedREF032420A

2U2UOther Payer ID (linked to 2330B Payer)REF04-12420A

1234554698REF04-22420A

ExampleIn the following example, the first column is a claim as submitted to the primary payer.The second column is the corresponding claim with the same business data as it wouldbe submitted to the secondary payer. For the COB claim to the secondary payer, thisexample shows information related to the primary payer being placed in the other

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(non-destination) payer locations, and it also shows information related to the secondarypayer being placed in the destination payer locations. Segments in red, italicized textare related to the secondary payer.

HEADER

ST*837*0002*005010X223~

BHT*0019*00*0123*20050730*1023*CH~

HEADER

ST*837*0002*005010X223~

BHT*0019*00*0123*20050730*1023*CH~

1000A SUBMITTER

NM1*41*2*GET WELL CLINIC*****46*567890~

PER*IC*MARY*TE*6155552222~

1000A SUBMITTER

NM1*41*2*GET WELL CLINIC*****46*567890~

PER*IC*MARY*TE*6155552222~

1000B RECEIVER

NM1*40*2*MY CLEARINGHOUSE*****46*988888888~

1000B RECEIVER

NM1*40*2*MY CLEARINGHOUSE*****46*988888888~

2000A BILLING/PAY-TO PROVIDER HL LOOP

HL*1**20*1~


HL*1**20*1~

2010AA BILLING PROVIDER

NM1*85*2*GET WELL CLINIC*****XX*5876543216~

N3*1234 MAIN ST~

N4*ANYWHERE*TN*37214~

REF*EI*111222333~


NM1*85*2*GET WELL CLINIC*****XX*5876543216~

N3*1234 MAIN ST~


REF*EI*111222333~

2000B SUBSCRIBER HL LOOP

HL*2*1*22*1~

SBR*S********CI~


HL*2*1*22*1~

SBR*P********BL~

2010BA SUBSCRIBER

NM1*IL*1*DOE*JANE****MI*JA7654321~

REF*SY*765432111~

2010BA SUBSCRIBER

NM1*IL*1*DOE*JOHN****MI*JD03398777~

REF*SY*033987777~

2010BB PAYER

NM1*PR*2*XYZ INS GROUP*****PI*54698~

REF*G2*XYZ3434343~

REF*LU*455~

2010BB PAYER

NM1*PR*2*ABC INS*****PI*12345~

REF*G2*12345678~

REF*LU*678~

2000C PATIENT HL LOOP

HL*3*2*23*0~

PAT*19~


HL*3*2*23*0~

PAT*19~

2010CA PATIENT

NM1*QC*1*DOE*SALLY~

N3*234 SOUTH ST~


DMG*D8*19930501*F~

2010CA PATIENT

NM1*QC*1*DOE*SALLY~

N3*234 SOUTH ST~


DMG*D8*19930501*F~

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2300 CLAIM

CLM*26407789*115***13:A:1*Y**Y*Y~

REF*G1*XYZ345200~

REF*9F*XYZ6798777~

HI*BK:4779*BF:2724*BF:2780*BF:53081~

2300 CLAIM

CLM*26407789*115***13:A:1*Y**Y*Y~

REF*G1*ABC456~

REF*9F*ABC670000~

HI*BK:4779*BF:2724*BF:2780*BF:53081~

2310A ATTENDING PROVIDER

NM1*AT*1*KILDARE*RICHARD****XX*9999977777~

REF*G2*XYZ6798666~

REF*LU*986~

2310A ATTENDING PROVIDER

NM1*AT*1*KILDARE*RICHARD****XX*9999977777~

REF*G2*ABC670001~

REF*LU*671~

2310D RENDERING PROVIDER

NM1*82*1*CASEY*BEN****XX*9999966666~

REF*G2*XYZ6798444~

REF*LU*984~

2310D RENDERING PROVIDER

NM1*82*1*CASEY*BEN****XX*9999966666~

REF*G2*ABC670002~

REF*LU*672~

2310E SERVICE FACILITY LOCATION

NM1*77*2*ANYWHERE CLINIC*****XX*9999955555~

N3*2345 STATE ST~

N4*NASHVILLE*TN*37212~

REF*G2*XYZ6798222~

REF*LU*982~

2310E SERVICE FACILITY LOCATION

NM1*77*2*ANYWHERE CLINIC*****XX*9999955555~

N3*2345 STATE ST~


REF*G2*ABC670004~

REF*LU*674~

2320 OTHER SUBSCRIBER INFORMATION

SBR*P*19*******BL~

AMT*D*65~

DMG*D8*19481013*M~

OI***Y*B**Y~


SBR*S*19*******CI~

DMG*D8*19500501*F~

OI***N*B**Y~

2330A OTHER SUBSCRIBER NAME

NM1*IL*1*DOE*JOHN****MI*JD03398777~

N3*234 SOUTH ST~


REF*SY*033987777~


NM1*IL*1*DOE*JANE****MI*JA7654321~

N3*234 SOUTH ST~


REF*SY*765432111~

2330B OTHER PAYER

NM1*PR*2*ABC INS*****PI*12345~

REF*F8*ABCCLM0005~

REF*G1*ABC456~

REF*9F*ABC670000~

2330B OTHER PAYER

NM1*PR*2*XYZ INS GROUP*****PI*54698~

REF*G1*XYZ345200~

REF*9F*XYZ6798777~

2330C OTHER PAYER ATTENDING PROVIDER

NM1*AT*1~

REF*G2*ABC670001~

REF*LU*671~

2330C OTHER PAYER ATTENDING PROVIDER

NM1*AT*1~

REF*G2*XYZ6798666~

REF*LU*986~

2330G OTHER PAYER RENDERING PROVIDER

NM1*82*1~

REF*G2*ABC670002~

REF*LU*672~

2330G OTHER PAYER RENDERING PROVIDER

NM1*82*1~

REF*G2*XYZ6798444~

REF*LU*984~

2330F OTHER PAYER SERVICE FACILITY LOCATION

NM1*77*2~

REF*G2*ABC670004~

REF*LU*674~

2330F OTHER PAYER SERVICE FACILITY LOCATION

NM1*77*2~

REF*G2*XYZ6798222~

REF*LU*982~

MAY 200616



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CLM*26407789*115***13:A:1*Y**Y*Y**********08~

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CLM*26407789*115***13:A:1*Y**Y*Y**********08~

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SERVICE LINE

LX*1~

SV2*0300*HC:99213*100*UN*1~

DTP*472*D8*20050705~

REF*G1*XYZ888888~

REF*G1*ABC222222**2U:12345~

REF*9F*XYZ777777~

REF*9F*ABC111111**2U:12345~

2400 SERVICE LINE

LX*1~

SV2*0300*HC:99213*100*UN*1~

DTP*472*D8*20050705~

REF*G1*ABC222222~

REF*G1*XYZ888888**2U:54698~

REF*9F*ABC111111~

REF*9F*XYZ777777**2U:54698~

2420C RENDERING PROVIDER

NM1*82*1*WELBY*MARCUS****XX*1545454541~

REF*G2*XYZ666666~

LU*Z666~

REF*G2*ABC333333**2U:12345~

REF*LU*C333**2U:12345~

2420C RENDERING PROVIDER

NM1*82*1*WELBY*MARCUS****XX*1545454541~

REF*G2*ABC333333~

REF*LU*C333~

REF*G2*XYZ666666**2U:54698~

REF*LU*Z666**2U:54698~

2420D REFERRING PROVIDER

NM1*DN*1*BROWN*JOE****XX*1323232321~

REF*G2*XYZ111111~

REF*LU*Z111~

REF*G2*ABC88888888**2U:12345~

REF*LU*C888**2U:12345~

2420D REFERRING PROVIDER

NM1*DN*1*BROWN*JOE****XX*1323232321~

REF*G2*ABC888888~

REF*LU*C888~

REF*G2*XYZ111111**2U:54698~

REF*LU*Z111**2U:54698~

2430 LINE ADJUDICATION INFORMATION

SVD*12345*50*HC:99213**1~

CAS*PR*1*50~

DTP*573*D8*20050726~

AMT*EAF*50~

2400 SERVICE LINE

LX*2~

SV2*0300*HC:90782*15*UN*1~

DTP*472*D8*20050705~

2400 SERVICE LINE

LX*2~

SV2*0300*HC:90782*15*UN*1~

DTP*472*D8*20050705~


SVD*12345*15*HC:90782**1~

CAS*PR*92*0~

DTP*573*D8*20050726~

TRANSACTION SET TRAILER

SE*88*0002~

TRANSACTION SET TRAILER

SE*78*0002~

1.4.1.3 Coordination of Benefits Claims from Paper or ProprietaryRemittance Advices

Claim submitters may at times need or choose to create electronic secondary/tertiarycoordination of benefit (COB) claims to subsequent payers due to regulatory or businessrelationships when the prior payer’s remittance was a paper or proprietary remittanceadvice. This situation may occur when the prior payer(s) is not a regular trading partner

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of the claim submitter or the prior payer(s) produces electronic remittances but has notconverted to the standard transaction.

Provider information systems that have the functionality to generate electronic claimtransactions to health plans have the majority of the information necessary to create aCOB claim. Ideally, payers have adopted usage of the standard codes sets for paperremittance advices or have provided crosswalks for their paper or non-standard electronicremittances to accommodate creation of COB claims. However, this will not alwaysoccur.

When standard codes are not available from a prior payer(s) paper/proprietary remittanceadvice(s), the COB claim submitter must translate the proprietary adjustment/denial editmessages to standard codes.

Generally, a subsequent COB payer(s) determines payment on a combination of “GroupCode” and “Claim Adjustment Reason Code” provided in the CAS segment at either theclaim or service line. The primary considerations of Group Code of subsequent COBpayers are:

837 Standard ValueDescription

PRPatient Responsibility

COContractual Obligation

PIPayer Initiated

OAOther Adjustments

The Claim Adjustment Reason Code is equally important in subsequent payers’determination of payment responsibility. In most instances paper or proprietary monetaryadjustments may easily be cross-walked to the standard Claim Adjustment ReasonCodes as follows:


Patient Responsibility

1Deductible Amount

2Coinsurance Amount

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3Co-payment Amount

66Blood Deductible

122Psychiatric Reduction

Contractual Obligations

42Charges exceed our fee schedule or maximum allowableamount

45Charges exceed your contracted / legislated fee arrangement

96Non-covered charges

Payment adjustments by the prior payer(s) that are not readily defined by the abovecross-walk values may be reported using default Claim Adjustment Reason Code 192(Non-standard adjustment code from paper remittance advice) or with other codes theclaim submitter determines to be appropriate. Submitters must not use default code 192when a more specific code is available.

1.4.1.4 Coordination of Benefits - Service Line Procedure CodeBundling and Unbundling

This explanation of bundling and unbundling is applicable to secondary claims that mustcontain the results of the primary payer’s processing. It is not applicable to initial claimssent to the primary payer.

Procedure code bundling or unbundling occurs when a payer’s business policy requiresthat the services reported for payment in a claim be either combined or split apart andrepresented by a different group of procedure codes. Bundling occurs when two or morereported procedure codes are paid under only one procedure code. Unbundling occurswhen one submitted procedure code is paid and reported back as two or more procedurecodes.

See the latest version of the 835 Remittance Advice transaction implementation guidefor an explanation on how bundling and unbundling are handled in that transaction.

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Bundling:In a COB situation, it may be necessary to show payment on bundled lines. Whenshowing bundled service lines, the health care claim must report all of the originallysubmitted service lines.The first bundled procedure includes the new bundled procedurecode in the SVD (Service Line Adjudication) segment (SVD03). The other procedure orprocedures that are bundled into the same line are reported as originally submitted withthe following:

• An SVD segment with zero payment (SVD02),• A pointer to the new bundled procedure code (SVD06, data element 554 (Assigned

Number) is the bundled service line number that refers to the LX assigned number ofthe service line into which this service line was bundled),

• A CAS segment with a claim adjustment reason code of 97 (payment is included inthe allowance for the basic service), and

• An adjustment amount equal to the submitted charge.• The Adjustment Group in the CAS01 will be either CO (Contractual Obligation) or PI

(Payer Initiated), depending upon the provider/payer relationship.

Bundling with COB ExampleThe following example shows how to report bundled lines on a subsequent COB claim.ABC Hospital submits procedure code A and B for $100.00 each to his PPO as primarycoverage. Each procedure was performed on the same date of service.The original 837submitted by ABC Hospital contains this information. Only segments specific to bundlingare included in the example.

Original 837LX*1~ (Loop 2400)1 = Service line 1

SV2*0300*HC:A*100*UN*1~

0300= UB Revenue CodeHC = HCPCS qualifierA = HCPCS code100 = Submitted chargeUN = Units code1 = Units billed

LX*2~ (Loop 2400)2 = Service line 2

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SV2*0300*HC:B*100*UN*1~

0300= UB Revenue CodeHC = HCPCS qualifierB = HCPCS code100 = Submitted chargeUN = Units code1 = Units billed

The PPO’s adjudication system screens the submitted procedures and notes thatprocedure C covers the services rendered by Dr. Smith on that single date of service.The PPO’s maximum allowed amount for procedure C is $120.00. The patient’sco-insurance amount for procedure C is $20.00. The patient has not met the $50.00deductible. The PPO’s total payment on this claim was $50.00. The following exampleincludes only segments specific to bundling. The key number to automate tracking ofbundled lines is the service line number assigned to each service line in LX01.

COB 837

Claim LevelCAS*PR*1*50~ (Loop ID-2320)PR = Patient’s Responsibility1 = Adjustment reason - Deductible amount50 = Amount of adjustment

AMT*D*50~

D = Payer amount paid qualifier50 = Amount paid on this claim by this payer

Service Line LevelLX*1~ (Loop ID-2400)1 = Service line 1

SV2*0300*HC:A*100*UN*1~ (Loop ID-2400)0300= UB Revenue CodeHC = HCPCS qualifierA = HCPCS code100 = Submitted chargeUN = Units code1 = Units billed

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SVD*PAYER ID*100*HC:C**1~ (Loop ID-2430)Payer ID

= ID of the payer who adjudicated this service line100 = Payer amount approved for payment for the lineHC = HCPCS qualifierC = HCPCS code for bundled procedure1 = Service Units

CAS*PR*2*20~

PR = Patient Responsibility2 = Adjustment reason -- Co-insurance amount20 = Amount of adjustment

LX*2~ (Loop 2400)2 = Service line 2

SV2*0300*HC:B*100*UN*1~

0300= UB Revenue CodeHC = HCPCS qualifierB = HCPCS code100 = Submitted chargeUN = Units code1 = Units billed

SVD*PAYER ID*0*HC:C**1*1~ (Loop ID-2430)Payer ID

= ID of the payer who adjudicated this service line0 = Payer amount paidHC = HCPCS qualifierC = HCPCS code for bundled procedure1 = Service Units1 = Service line number into which this service line was bundled

CAS*CO*97*100~

CO = Contractual obligations qualifier97 = Adjustment reason - Payment is included in the allowance for the basicservice/procedure100 = Amount of adjustment

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Bundling with COB -– More Than 2 Payers ExampleBundling with more than two payers in a COB situation where there is both bundling andline level adjustments. The COB related loops would appear as follows:

Claim Level 2320 and 2330 Loops2320 Loop (for payer A)SBR* identifies the other subscriber for payer A identified in 2330B

2330A LoopNM1* identifies other subscriber for payer A

2330B LoopNM1* identifies payer A

2320 Loop (for payer B)SBR* identifies the other subscriber for payer B identified in 2330B loop

2330A LoopNM1* identifies other subscriber for payer B

2330B LoopNM1* identifies payer B

2320 Loop (for payer C)SBR* identifies the other subscriber for payer C identified in 2330B loop

2330A LoopNM1* identifies other subscriber for payer C

2330B LoopNM1* identifies payer C

Repeat as necessary up to a maximum of ten times. Any one claim can carry up to atotal of 11 payers (ten carried in Loop ID-2320, and one carried in Loop ID-2010BB).Once all the claim level payers have been identified, use the 2400 loop once for eachoriginal billed service line. Use 2430 loops to show line level adjustment by each payer.

Service Line

2400 LoopLX*1~

SV2* original data from provider for line 1

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2430 Loop (for payer A)SVD*A* their data for this line (the procedure code A paid on)CAS* payer A’s data for this line (repeat CAS as necessary)DTP* payer A’s adjudication date for this line

2430 Loop (for payer B)SVD*B* their data for this line (the procedure code B paid on)CAS* payer B’s data for this line (repeat CAS as necessary)DTP* payer B’s adjudication date for this line

2430 Loop (for payer C, only used if 837 is being sent to payer D)SVD*C* their data for this line (the procedure code C paid on)CAS* payer C’s data for this line (repeat CAS as necessary)DTP* payer C’s adjudication date for this line

2400 LoopLX*2~

SV2* original data from provider for line 2

2430 Loop (for payer A)SVD*A* their data for this line (the procedure code A paid on)CAS* payer A’s data for this line (repeat CAS as necessary)DTP* payer A’s adjudication date for this line

2430 Loop (for payer B)SVD*B* their data for this line (the procedure code B paid on)CAS* payer B’s data for this line (repeat CAS as necessary)DTP* payer B’s adjudication date for this line

2430 Loop (for payer C, only used if 837 is being sent to payer D)SVD*C* their data for this line (the procedure code C paid on)CAS* payer C’s data for this line (repeat CAS as necessary)DTP* payer C’s adjudication date for this line

etc.

Unbundling with COBWhen unbundling, the original service line detail will be followed by one or moreoccurrences of the Line Adjudication Information (Loop ID-2430) loop. This loop isrepeated once for each unbundled procedure code.

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Unbundling ExampleThe same provider submits a claim for one service line. The billed service procedurecode is A, with a submitted charge of $200.00.The payer unbundled this into two services-- B and C -- each with an allowed amount of $60.00. There is no deductible orco-insurance amount. Only segments specific to unbundling are included in the followingexample.

LX*1~ (Loop-2400)1 = Service line 1

SV2*0300*HC:A*200*UN*1~

0300= UB Revenue CodeHC = HCPCS qualifierA = HCPCS code200 = Submitted chargeUN = Units code1 = Units billed

SVD*PAYER ID*60*HC:B**1~ (Loop ID-2430)Payer ID

= ID of the payer who adjudicated this service line60 = Payer amount paidHC = HCPCS qualifierB = Unbundled HCPCS code1 = Service Units

CAS*CO*45*35~

CO = Contractual obligations qualifier45 = Adjustment reason -- Charges exceed your contracted/legislated fee arrangement35 = Amount of adjustment

SVD*PAYER ID*60*HC:C**1~

Payer ID

= ID of the payer who adjudicated this service line60 = Payer amount paidHC = HCPCS qualifierC = Unbundled HCPCS code1 = Service Units

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CAS*CO*45*45~

CO = Contractual obligations qualifier45 = Adjustment reason -- Charges exceed your contracted/legislated fee arrangement45 = Amount of adjustment

1.4.1.5 Coordination of Benefits - Medicaid SubrogationFederal law requires Medicaid agencies to pursue recovery of medical expendituresmade on behalf of Medicaid recipients when third party liability is determined to exist.Since Medicaid recipients are required to assign any rights of third party liability to theMedicaid agency, this Implementation Guide provides the ability for willing trading partnersto allow direct billing by a Medicaid agency to other health plans. These pay-to-planclaims are identified by the inclusion of Loop ID-2010AC Pay-to Plan Name Loop.Medicaid subrogation claims include the Medicaid agency’s own payer claim controlnumber in Loop ID-2300 data element CLM01 rather than the provider’s patient controlnumber. The Medicaid paid amount, indicated in Loop ID-2320 data element AMT01,represents the maximum amount of liability the Medicaid agency is requesting to recoverby submitting the claim.

The Medicaid agency is identified in Loop ID-2330B (Other Payer Name). Loop ID-2320and Loop ID-2430 include all required segments to indicate the Medicaid agency’sadjudication of the original claim submitted to that agency. Receiving payers are to directinformation requests about the claim to the Medicaid agency rather than to the originalservice provider.

At the time of publication, Medicaid subrogation is not a HIPAA mandated businessusage of the ASC X12 837 Health Care Claim, but willing trading partners may use thisImplementation Guide for that purpose.

1.4.2 Property and CasualtyTo ensure timely processing, specific information needs to be included when submittingbills to Property and Casualty payers (for example, Automobile, Homeowner’s, or Workers’Compensation insurers and related entities). Section 3.2 of this Implementation Guideexplains these requirements and presents a number of examples.

1.4.3 Data OverviewThe data overview introduces the 837 transaction set structure and describes thepositioning of business data within the structure. For a review of ASC X12 nomenclature,segments, data elements, hierarchical levels, and looping structure, see Appendix B,Nomenclature, and Appendix C, EDI Control Directory.

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an example.

1.4.3.1 Loop Labeling, Sequence, and UseThe 837 transaction uses two naming conventions for loops. Loops are labeled with adescriptive name as well as with a shorthand label. Loop ID-2000A BILLING PROVIDERcontains information about the billing provider, pay-to address and pay-to plan. Thedescriptive name -- BILLING PROVIDER -- informs the user of the overall focus of theloop. The Loop ID is a short-hand name, for example 2000A, that gives, at a glance, theposition of the loop within the overall transaction. Loop ID-2010AA BILLING PROVIDERNAME, Loop ID-2010AB PAY-TO ADDRESS NAME, and Loop ID-2010AC PAY-TOPLAN NAME are subloops of Loop ID-2000A. When a loop is used more than once, aletter is appended to its numeric portion to allow the user to distinguish the variousiterations of that loop when using the shorthand name of the loop. For example, loop2000 has three possible iterations: Billing Provider Hierarchical Level (HL), SubscriberHL and Patient HL. These loops are labeled 2000A, 2000B and 2000C respectively. Asthe 2000 level loops define the hierarchical structure, they are required to be used inthe order shown in the implementation guide.

The order of multiple subloops that do not involve hierarchical structure and that do havethe same numeric position within the transaction is less important. Such subloops donot need to be sent in the same order in which they appear in this implementation guide.For such subloops in this transaction, the numeric portion of the loop ID does not endin 00. For example, Loop ID-2010 has two possibilities within Loop ID-2000B (LoopID-2010BA Subscriber Name and Loop ID-2010BB Payer Name). Each of these 2010loops is at the same numeric position in the transaction. Since they do not specify anHL, it is not necessary to use them in any particular order. However, it is not acceptableto send subloop 2330 before loop 2310 because these are not equivalent subloops.

In a similar manner, if a single loop has multiple iterations (repetitions) of a particularsegment, the sequence of those segments within a transaction is not important and isnot required to follow the same order in which they appear in this implementation guide.For example, there are many DTP segments in the 2300 loop. It is not required thatInitial Treatment Date be sent before Last Seen Date. However, it is required that theDTP segment in the 2300 loop come after the CLM segment because it is carried in adifferent position within the 2300 loop.

1.4.3.2 Data Use by Business UseThe 837 is divided into two tables. Table 1 contains transaction control information andis described in Section 1.4.3.2.1 - Table 1 -- Transaction Control Information. Table 2contains the detail information for the transaction’s business function and is describedin Section 1.4.3.2.2 - Table 2 -- Detail Information.

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REF segments in the 2300 loop. It is not required that the Referral Number segment be sent before the Claim Identifier for Transmission Intermediaries segment. However, it is required that the REF segment(s) in the 2300 loop be sent after the CLM segment because they are specified in a different position within the 2300 loop.

1.4.3.2.1 Table 1 -- Transaction Control InformationTable 1 is named the Header level (see Figure 1.3 - Header Level). Table 1 identifiesthe start of a transaction, the specific transaction set, the transaction’s business purpose,and the submitter/receiver identification numbers.

Figure 1.3 - Header Level

1.4.3.2.1.1 Transaction Set Header (ST) SegmentThe Transaction Set Header (ST) segment identifies the transaction set by using 837as the data value for the transaction set identifier code data element, ST01. Thetransaction set originator assigns the unique transaction set control number ST02.

Because the 837 is multi-functional, it is important for the receiver to know which businesspurpose is served. ST03 contains a reference to the specific implementation guide usedto create this 837 transaction. This data element differentiates among the Health CareClaim: Professional (005010X222), the Health Care Claim: Institutional (005010X223),the Health Care Claim: Dental (005010X224), and the health Care Service: DataReporting (005010X225).

1.4.3.2.1.2 Beginning of Hierarchical Transaction (BHT) SegmentThe BHT segment indicates that the transaction uses a hierarchical data structure. Thedata elements within the BHT are used in the following way:

• BHT01 - The Hierarchical Structure Code designates the type of business data withineach hierarchical level. The 0019 value used in the claim BHT01 specifies the orderof subsequent hierarchical levels to be:• Information source (Billing Provider)• Subscriber (can be the patient when the patient is the subscriber or is considered to

be the subscriber)• Dependent (Patient, when the patient is not considered to be the subscriber)

• BHT02 - The transaction purpose code indicates “original” by using data value 00 or“reissue” by using data value 18.

• BHT03 - originator’s reference number; generated by the business application systemof the entity building the original transaction.

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the Health Care Service: Data Reporting (005010X225), the Health Care Predetermination: Professional (005010X291) and the Health Care Predetermination: Institutional (005010X292).

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• BHT04 - date of transaction creation; generated by the business application systemof the entity building the original transaction.

• BHT05 - time of transaction creation; generated by the business application systemof the entity building the original transaction.

• BHT06 - designates transaction as Subrogation, fee-for-service, or capitated services.

1.4.3.2.2 Table 2 -- Detail InformationTable 2 uses the hierarchical level structure. Each hierarchical level is comprised of aseries of loops. Numbers identify the loops. The hierarchical level in Loop ID-2000identifies the participants and the relationship to other participants. The individual orentity information is contained in Loop ID-2010.

1.4.3.2.2.1 Hierarchical Level (HL) SegmentsSection B.1.1.4.3 in Appendix B contains a general description of HL structures. Thefollowing describes the HL structure within the claim transaction.

The Billing Provider or Subscriber HLs may contain multiple “child” HLs. A child HLindicates an HL that is nested within (subordinate to) the previous HL. Hierarchical levelsmay also have a parent HL. A parent HL is the HL that is one level out in the nestingstructure. An example follows.

Parent HL to the Subscriber HLBilling provider HL

Parent HL to the Patient HL; Child HL to the Billing Provider HLSubscriber HL

Child HL to the Subscriber HLPatient HL

For the Subscriber HL, the Billing Provider HL is the parent. The Patient HL is the child.The Subscriber HL is contained within the Billing Provider HL.The Patient HL is containedwithin the Subscriber HL.

1.4.3.2.2.2 Subscriber / Patient Hierarchical Level (HL) SegmentsThe following information illustrates claim submissions when the patient is the subscriberand when the patient is not the subscriber.

NOTESpecific claim detail information can be given in either the subscriber or the dependenthierarchical level. Because of this, the claim information is said to “float.” Claim informationis positioned in the same hierarchical level that describes its owner-participant, eitherthe subscriber or the patient. In other words, the claim information is placed at thesubscriber hierarchical level when the patient is the subscriber or considered to be the

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fee-for-service

subscriber, or it is placed at the patient/dependent hierarchical level when the patient isthe dependent of the subscriber and cannot be uniquely identified on their own.

Claim submission when the patient is the subscriber or is considered to be thesubscriber:Billing provider (HL03=20)

Subscriber (HL03=22)Claim level informationLine level information, as needed

Claim/encounter submission when the patient is not the subscriber:Billing provider (HL03=20)

Subscriber (HL03=22)Patient (HL03=23)

Claim level informationLine level information, as needed

1.4.3.2.2.3 Hierarchical Level (HL) Structural ExampleIf the billing provider is submitting claims for more than one subscriber, each of whommay or may not have dependents, the HL structure between the transaction set headerand trailer (ST-SE) could look like the following:

BILLING PROVIDERSUBSCRIBER #1 (Patient #1)


SUBSCRIBER #2PATIENT #P2.1 (for example, subscriber #2 spouse)


PATIENT #P2.2 (for example, subscriber #2 first child)Claim level informationLine level information, as needed

PATIENT #P2.3 (for example, subscriber #2 second child)Claim level informationLine level information, as needed

SUBSCRIBER #3 (Patient #3)Claim level informationLine level information, as needed

SUBSCRIBER #4 (Patient #4)

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SUBSCRIBER #4 (repeated)PATIENT #P4.1 (for example, #4 subscriber’s first child)


Based on the previous example, the HL structure will be as follows:

HL*1**20*1~ (BILLING PROVIDER)1 = HL sequence number**(blank)

= there is no parent HL (characteristic of the billing provider HL)20 = information source1 = there is at least one child HL to this HL

HL*2*1*22*0~ (SUBSCRIBER #1)2 = HL sequence number1 = parent HL22 = subscriber0 = no subordinate HLs to this HL (there is no child HL to this HL - claim level datafollows)

HL*3*1*22*1~ (SUBSCRIBER #2)3 = HL sequence number1 = parent HL22 = subscriber1 = there is at least one child HL to this HL

HL*4*3*23*0~ (PATIENT #P2.1)4 = HL sequence number3 = parent HL23 = dependent0 = no subordinate HLs in this HL (there is no child HL to this HL - data follows)

HL*5*3*23*0~ (PATIENT #P2.2)5 = HL sequence number3 = parent HL23 = dependent

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0 = no subordinate HLs in this HL (there is no child HL to this HL - claim level datafollows)

HL*6*3*23*0~ (PATIENT #P2.3)6 = HL sequence number3 = parent HL23 = dependent0 = no subordinate HLs in this HL (there is no child HL to this HL - claim level datafollows)

HL*7*1*22*0~ (SUBSCRIBER AND PATIENT #3)7 = HL sequence number1 = parent HL22 = subscriber0 = no subordinate HLs in this HL (there is no child HL to this HL - claim level datafollows)

HL*8*1*22*0~ (SUBSCRIBER AND PATIENT #4)8 = HL sequence number1 = parent HL22 = subscriber0 = no subordinate HLs

HL*9*1*22*1~ (SUBSCRIBER #4)9 = HL sequence number1 = parent HL22 = subscriber1 = there is at least one child HL to this HL

HL*10*9*23*0~ (PATIENT #P4.1)10 = HL sequence number9 = parent HL23 = dependent0 = no subordinate HLs

If another billing provider is listed in the same ST-SE functional group, it could be listedas follows: HL*100**20*1~. The HL sequence number of 100 indicates that there are99 previous HL segments and it is the billing provider level HL (HL03 = 20).

1.4.3.2.2.4 Hierarchical Level (HL) Structural SummaryThe following information summarizes coding and structure of the HL segment:

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• HL segments are numbered sequentially within a transaction (ST to SE), beginningwith 1. The sequential number is found in HL01, which is the first data element in theHL segment. Sequence number must be numeric.

• The second element, HL02, indicates the sequential number of the parent hierarchicallevel. The billing provider/information source is the highest hierarchical level andtherefore has no parent.

• The data value in data element HL03 describes the hierarchical level entity. Forexample, when HL03 equals 20, the hierarchical level is the billing provider; whenHL03 equals 23, the hierarchical level is the dependent (patient).

• Data element HL04 indicates whether or not subordinate hierarchical levels exist. Avalue of "1" indicates subsequent hierarchical levels. A value of ”0" indicates nosubordinate hierarchical levels exist for this HL.

1.4.3.2.2.5 Claim StructureAfter the HL structure is defined and the Subscriber and/or Patient information is listed,the specific claim information follows:

• Loop ID-2300 contains claim level information.• Loop ID-2310 identifies various claim specific providers who may have been involved

in the health care services being reported in the transaction.• Loop ID-2320 identifies claim level adjudication information associated with

non-destination, other payer information for the purpose of coordination of benefits.• Loop ID-2330 identifies the subscriber, payer, and provider identifiers associated with

the non-destination, other payer.• Loop ID-2400 is required for all claims and identifies service line information.• Loop ID-2410 identifies drug and biologics information.• Loop ID-2420 identifies any service line providers who are different than claim level

providers.• Loop ID-2430 identifies any service line adjudication information from another payer.

1.4.3.2.2.6 Provider Taxonomy Code ReportingProvider Taxonomy Codes describe provider type, classification, and area of specializationand are maintained by the National Uniform Claims Committee. For use in an 837 claim,the provider determines the code value from the code set (external Code Source 682)that most accurately describes the type and specialty classification under which theprovider performed the services reported on the claim. The payer may not dictate thecode value to be reported.

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1.4.4 BalancingIn order to ensure internal claim integrity, amounts reported in the 837 MUST balanceat two different levels -- the claim and the service line.

1.4.4.1 Claim LevelThere are two different ways the claim information must balance. They are as follows.

1) Claim Charge AmountsThe total claim charge amount reported in Loop ID-2300 CLM02 must balance to thesum of all service line charge amounts reported in Loop ID-2400 SV203.

2) Claim Payment AmountsBalancing of claim payment information is done payer by payer. For a given payer, thesum of all line level payment amounts (Loop ID-2430 SVD02) less any claim leveladjustment amounts (Loop ID-2320 CAS adjustments) must balance to the claim levelpayment amount (Loop ID-2320 AMT02).

Expressed as a calculation for given payer: {Loop ID-2320 AMT02 payer payment} ={sum of Loop ID-2430 SVD02 payment amounts} minus {sum of Loop ID-2320 CASadjustment amounts}.

Line Level Payment AmountsLine level payment information is reported in Loop ID-2430 SVD02. In order toperform the balancing function, the receiver must know which payer the line paymentbelongs to. This is accomplished using the identifier reported in Loop ID-2430SVD01.This identifier must match the identifier of the corresponding payer identifierreported in Loop ID-2330B NM109.

Adjustment CalculationsAdjustments are reported in the CAS segments of Loop ID-2320 (claim level) andLoop ID-2430 (line level). In this context, Adjustment Amounts are the sum of CAS03,CAS06, CAS09, CAS12, CAS15, and CAS18. Adjustment amounts within the CASsegment DECREASE the payment amount when the adjustment amount isPOSITIVE, and INCREASE the payment amount when the adjustment amount isNEGATIVE.

Claim Level Payment AmountAt the claim level, the payer’s total claim payment is reported within the Loop ID-2320Coordination of Benefits (COB) Payer Paid Amount AMT segment with a D qualifierin AMT01. The associated payer is defined within the Loop ID-2330B child loop.

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Example:Claim Charge - 100.00Claim Payment - 80.00Claim Adjustment - 5.00

Line 1 Charge - 80.00Line 1 Payment - 70.00Line 1 Adjustment - 10.00


Claim Payment = (Line 1 Payment + Line 2 Payment) – Claim Adjustment

80.00 = (70.00 + 15.00) - 5.00

1.4.4.2 Service LineLine Adjudication Information (Loop ID-2430) is reported when the payer identified inLoop ID-2330B has adjudicated the claim and service line payments and/or adjustmentshave been applied.

Line level balancing occurs independently for each individual Line Adjudication Informationloop. In order to balance, the sum of the line level adjustment amounts and line levelpayments in each Line Adjudication Information loop must balance to the provider’scharge for that line (Loop ID-2400 SV203). The Line Adjudication Information loop canrepeat up to 25 times for each line item.

The calculation for each 2430 loop is as follows: {sum of Loop ID-2430 CAS ServiceLine Adjustments} plus {Loop ID-2430 SVD02 Service Line Paid Amount} = {Loop ID-2400SV203 Line Item Charge Amount}

Example:Line 1 Charge - 80.00Line 1 Payment - 70.00Line 1 Adjustment - 10.00


(Line 1 Adjustments) + (Line 1 Payment) = Line Item 1 Charge

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Line

John

Line

10.00 + 70.00 = 80.00

(Line 2 Adjustments) + (Line 2 Payment) = Line Item 2 Charge

5.00 + 15.00 = 20.00

1.4.5 Allowed/Approved Amount CalculationDuring the development cycle of this version, one of the guiding principles was to removeall amount fields that can be calculated with other information already present in theclaim. This resulted in the elimination of several AMT segments. Included in these, arethe Approved and Allowed Amount segments.The workgroup has found these amountsvary in definition depending upon perspective. Although rare, there are times theprovider’s determination of what the allowed amount is different from the payers. Thisoccurs for many various reasons. However, there has never been a way to recognizewhen these differences occur. As a result, the authors offer the following guidance asto how these amounts are calculated.

The Allowed amount as determined by the payer is calculated using the prior payer'spayment information coupled with adjustment information in the CAS segments. Theprior payer payment + the sum total of all patient responsible adjustment amounts = theAllowed amount. The Patient Responsible adjustments are identified by use of theCategory Code PR in CAS01.

The Allowed amount as determined by the provider is calculated using the prior payer'spayment information coupled with the Remaining Patient Liability AMT segments. Theprior payer payment + the Remaining Patient Liability AMT amount = the Allowed amount.

1.5 Business TerminologyThis section defines terms used in this implementation guide that are not included in theData Dictionary Appendix. See the Data Dictionary Appendix for additional terms anddefinitions.

BundlingBundling occurs when a provider submits two or more reported procedure codes andthe payer believes that the actual services performed and reported must be paid underonly one (possibly different) procedure code.

ClaimFor the purposes of this implementation guide, claim is intended to be an all inclusiveterm to represent both reimbursable claims and encounter reporting.

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DependentIn the hierarchical loop coding, the dependent code 23 indicates the use of the PatientHierarchical loop (Loop ID-2000C).

Destination PayerThe destination payer is the payer who is specified in the Subscriber/Payer loop (LoopID-2010BB).

EncounterNon-reimbursable claim for which the health care encounter information is gathered forreporting. Also thought of as the reporting of a face-to-face encounter between a patientand a provider for which no reimbursement will be made. Often seen in pre-paid capitatedfinancial arrangements in which the provider of services is paid in advance for the patient'shealth care needs. In some areas called a capitated or zero pay claim.

InpatientThe determination of what constitutes an Inpatient Claim is defined by the NationalUniform Billing Committee code set and documentation. See Section 1.12.6 - Inpatientand Outpatient Designation for more information about Inpatient and Outpatientdesignation.

OutpatientThe determination of what constitutes an Outpatient Claim is defined by the NationalUniform Billing Committee code set and documentation. See Section 1.12.6 - Inpatientand Outpatient Designation for more information about Inpatient and Outpatientdesignation.

Pay-To Plan ClaimsPay-to plan claims are payment requests billed by one health plan directly to other healthplans. These claims were originally submitted to and paid by the first health plan. Anexample of a pay-to plan claim is a payment request from a Medicaid agency direct toanother health plan that may have liability for the member and services on the claimoriginally paid by the Medicaid agency.

PatientThe term patient is used in this implementation guide when the Patient loop (LoopID-2000C) is used. In Loop ID-2000C, the patient is not the same person as thesubscriber, and the patient is a person (for example, spouse, children, others) who iscovered by the subscriber’s insurance plan and does not have a unique memberidentification number. The person receiving services (in clinical terms, the patient) can

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be the same person as the subscriber. In that case, all information about that person iscarried in the Subscriber loop (Loop ID-2000B).

See Section 1.4.3.2.2.2 - Subscriber / Patient Hierarchical Level (HL) Segments, andthe notes for the SBR and PAT segments for further details. Every effort has been madeto ensure that the meaning of the word patient is clear in its specific context.

ProviderA provider is either a person or organizational entity who has either provided orparticipated in some aspect of the service(s) described in the transaction. Specific typesof providers are identified in this implementation guide (for example billing provider,referring provider). Beginning with the 5010 version, the Billing Provider must be a healthcare or atypical provider (as described in Section 1.10.1 - Providers who are Not Eligiblefor Enumeration).

Secondary PayerThe term secondary payer indicates any payer who is not the primary payer. Thesecondary payer may be the secondary, tertiary, or even quaternary payer.

SubscriberThe subscriber is the person whose name is listed in the health insurance policy, or whohas a unique member identification number. Other synonymous terms include memberand/or insured. In some cases the subscriber is the person receiving services. See thedefinition of patient, and see Section 1.4.3.2.2.2 - Subscriber / Patient Hierarchical Level(HL) Segments, and the notes for the SBR and PAT segments for further details.

Transmission IntermediaryA transmission intermediary is any entity that handles the transaction between theprovider (originator of the claim transmission) and the destination payer. The termintermediary is not used to convey a specific Medicare contractor type.

UnbundlingUnbundling occurs when a provider is billing multiple procedure codes for a group ofprocedures that are covered by a single comprehensive code. In other words, the providersubmits one reported procedure code and the payer believes that the actual servicesperformed and reported must be paid under two or more separate (possibly different)procedure codes. Unbundling also occurs when the units of service reported on oneservice line are broken out to two or more service lines for different reimbursement rates.

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Predetermination A predetermination of benefits (or predetermination) is a pre-service request for a statement of the exact benefits that would have been paid had the predetermination been an actual claim. The predetermination request would include all data necessary to fully adjudicate a claim except for date(s) of service.

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1.6 Transaction Acknowledgments There are several acknowledgment transactions available for use. The IG developers have noted acknowledgment requirements in this section. Willing trading partners may implement alternative acknowledgment agreements. The Workgroup for Electronic Data Interchange (WEDI) has also documented recommendations for standard acknowledgment reporting ("WEDI Acknowledgement Recommendations for ASC X12N Implementation Guides," Copyright (c) 2005 by WEDI).

1.6.1 997 Functional Acknowledgment The 997 informs the submitter that the functional group arrived at the destination. It may include information about the syntactical quality of the functional group. The Functional Acknowledgment (997) transaction is not required as a response to receipt of a batch transaction compliant with this implementation guide. The Functional Acknowledgment (997) transaction is not required as a response to receipt of a real-time transaction compliant with this implementation guide. The "Functional Acknowledgment for Health Care Insurance" Implementation Guide is available for insurance industry use.

1.6.2 999 Implementation Acknowledgment The 999 informs the submitter that the functional group arrived at the destination. It may include information about the syntactical quality of the functional group and the implementation guide compliance. The Implementation Acknowledgment (999) transaction is required as a response to receipt of a batch transaction compliant with this implementation guide. The Implementation Acknowledgment (999) transaction is not required as a response to receipt of a real-time transaction compliant with this implementation guide. The "Implementation Acknowledgment for Health Care Insurance" Implementation Guide is available for insurance industry use.

1.6.3 824 Application Advice The 824 informs the submitter of the results of the receiving application system's data content edits of transaction sets. The Application Advice (824) transaction is not required as a response to receipt of a batch transaction compliant with this implementation guide. The Application Advice (824) transaction is not required as a response to receipt of a real-time transaction compliant with this implementation guide.

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Use this page and the following page as a replacement for Section 1.6. (The common content portions of Section 1.6 are included with the indicated choices made.)

The "Application Reporting for Insurance" Implementation Guide is available for insurance industry use.

1.6.4 277 Health Care Claim Acknowledgment The 277 provides an application level acknowledgment of electronic predetermination requests. It may include information about the business validity and acceptability of the predetermination requests. The Health Care Claim Acknowledgment (277) transaction is not required as a response to receipt of a batch transaction compliant with this implementation guide. The Health Care Claim Acknowledgment (277) transaction is not required as a response to receipt of a real-time transaction compliant with this implementation guide.

1.6.5 835 Health Care Claim Payment/Advice The 835 Payment Remittance Advice TR3 describes the use of the ANSI ASC X12 Health Care Claim Payment/Advice (835) transaction set in response to a predetermination or estimate (837).

1.6.6 Responses to Real-time Transactions When in real time mode, the receiver must send an acknowledgment of one and only one of the following transactions:

The 835 Claim Payment / Remittance Advice The 277 Health Care Claim Acknowledgment The 999 Implementation Acknowledgment (or the 997 Functional

Acknowledgment) The TA1 Interchange Acknowledgment

1.6 Transaction AcknowledgmentsThere are several acknowledgment implementation transactions available for use. TheIG developers have noted acknowledgment requirements in this section. Otherrecommendations of acknowledgment transactions may be used at the discretion of thetrading partners. A statement that the acknowledgment is not required does not precludeits use between willing trading partners.

1.6.1 997 Functional AcknowledgmentThe 997 informs the submitter that the functional group arrived at the destination. It mayinclude information about the syntactical quality of the functional group.

The Functional Acknowledgment (997) transaction is not required as a response toreceipt of a batch transaction compliant with this implementation guide.

The Functional Acknowledgment (997) transaction is not required as a response toreceipt of a real-time transaction compliant with this implementation guide.

A 997 Implementation Guide is being developed for use by the insurance industry andis expected to be available for use with this version of this Implementation Guide.

1.6.2 999 Implementation AcknowledgmentThe 999 informs the submitter that the functional group arrived at the destination. It mayinclude information about the syntactical quality of the functional group and theimplementation guide compliance.

The Implementation Acknowledgment (999) transaction is not required as a responseto receipt of a batch transaction compliant with this implementation guide.

The Implementation Acknowledgment (999) transaction is not required as a responseto receipt of a real-time transaction compliant with this implementation guide.

A 999 Implementation Guide is being developed for use by the insurance industry andis expected to be available for use with this version of this Implementation Guide.

1.6.3 824 Application AdviceThe 824 informs the submitter of the results of the receiving application system's datacontent edits of transaction sets.

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The Application Advice (824) transaction is not required as a response to receipt of abatch transaction compliant with this implementation guide.

The Application Advice (824) transaction is not required as a response to receipt of areal-time transaction compliant with this implementation guide.

An 824 Implementation Guide is being developed for use by the insurance industry andis expected to be available for use with this version of this Implementation Guide.

1.6.4 277 Health Care Claim AcknowledgmentThe 277 provides an application level acknowledgment of electronic claims. It mayinclude information about the business validity and acceptability of the claims.

The Health Care Claim Acknowledgment (277) transaction is not required as a responseto receipt of a batch transaction compliant with this implementation guide.

The Health Care Claim Acknowledgment (277) transaction is not required as a responseto receipt of a real-time transaction compliant with this implementation guide.

1.7 Related TransactionsThere are one or more transactions related to the transactions described in thisimplementation guide.

1.7.1 Health Care Claim Payment/Advice (835)Information in the Health Care Claim Payment/Advice (835) transaction is generated bythe payer’s adjudication system. However, in a coordination of benefits (COB) situationwhere the provider is sending an 837 to a secondary payer, information from the 835may be included in the secondary 837. As shown in Section 1.4.1.2 - Crosswalking COBData Elements, data from specific segments/elements in the 835 are crosswalked directlyinto the subsequent 837.

1.8 Trading Partner AgreementsTrading partner agreements are used to establish and document the relationship betweentrading partners. A trading partner agreement must not override the specifications in thisimplementation guide if a transmission is reported in GS08 to be a product of thisimplementation guide.

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1.9 HIPAA Role in Implementation GuidesAdministrative Simplification provisions of the Health Insurance Portability andAccountability Act of 1996 (PL 104-191 - known as HIPAA) direct the Secretary of Healthand Human Services to adopt standards for transactions to enable health informationto be exchanged electronically and to adopt specifications for implementing eachstandard.

This implementation guide has been developed for use as an insurance industryimplementation guide. At the time of publication it has not been adopted as a HIPAAstandard. Should the Secretary adopt this implementation guide as a standard, theSecretary will establish compliance dates for its use by HIPAA covered entities.

1.10 National Provider Identifier Usage withinthe HIPAA 837 Transaction

Implementation and use of the National Provider Identifier (NPI) has a direct impact onthe generation of 837 transaction sets. Previous versions contained placeholder codesand elements in anticipation of the official Rule. With publication of the final rule andindustry input on implementation direction, the authors have identified the following areasfor clarification and direction for use within the implementation guide.

• Providers who are not eligible for enumeration• Implementation migration strategy• Organization health care provider subpart representation• Subparts and the billing provider

1.10.1 Providers who are Not Eligible for EnumerationAtypical providers are service providers that do not meet the definition of health careprovider. Examples include taxi drivers, carpenters, personal care providers, etc. Although,they are not eligible to receive an NPI, these providers perform services that arereimbursed by some health plans. As a result, this implementation guide has beenenhanced to accommodate both the NPI (to identify health care providers) and proprietaryidentifiers (to identify atypical/non-health care providers).

1.10.2 Implementation Migration StrategyThe ANSI ASC X12N Health Care Claims workgroup (TG2WG2) anticipates that duringthe transition period (i.e., the period from May 23, 2005 until the NPI compliance dates),

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the need to use both the NPI and proprietary identifiers to identify health care providersin the same standard claims transaction will be necessary. The implementation guidesfor the 837 transaction set have been modified to meet this need.

1.10.3 Organization Health Care Provider SubpartRepresentation

Historically, there has been no standard representation of organization health careproviders. How the health care provider entity has been identified has varied by tradingpartner. The NPI subpart concept provides an organization health care provider theability to represent itself in a manner consistent to all trading partners. In the health careclaim, there are three possible locations for organization health care provider entities tobe reported. They are Billing Provider, Rendering Provider, and Service Location.

Billing Provider. In many instances the Billing Provider is an organization; therefore,the Billing Provider NPI reported would belong to an organization health careprovider. The Billing Provider may be an individual only when the services wereperformed by, and will be paid to, an independent, non-incorporated individual.When an organization health care provider has determined that it has subpartsrequiring enumeration, that organization health care provider will report the NPI ofthe subpart as the Billing Provider. The subpart reported as the Billing ProviderMUST always represent the most detailed level of enumeration as determined bythe organization health care provider and MUST be the same identifier sent to anytrading partner.

NOTEIn published versions prior to 5010, the Billing Provider may have been a variety ofentities, including billing services and healthcare clearinghouses. Beginning withversion 5010, the Billing Provider must be a health care or atypical service provider(as described in the section entitled Providers who are Not Eligible for Enumeration).

Rendering Provider or Service Location. An organization health care provider’sNPI used to identify the Rendering Provider or the Service Location must be externalto the entity identified as the Billing Provider (for example; reference lab). It is notpermissible to report an organization health care provider’s NPI as the RenderingProvider or the Service Location if the Rendering Provider or Service Location is asubpart of the Billing Provider.

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1.10.4 Subparts and the 2010 AA - Billing ProviderName Loop

Beginning on the NPI compliance date(s): When the Billing Provider is an organizationhealth care provider, the NPI of the organization health care provider or its subpart isreported in NM109. When an organization health care provider has determined a needto enumerate subparts, it is required that a subpart’s NPI be reported as the BillingProvider. The subpart reported as the Billing Provider MUST always represent the mostdetailed level of enumeration and MUST be the same identifier sent to any tradingpartner. For additional explanation, see Section 1.10.3 - Organization Health CareProvider Subpart Representation.

The Billing Provider may be an individual only when the health care provider performingservices is an independent, unincorporated entity. In these cases, the Billing Provideris the individual whose Tax Identification Number (TIN) is used for IRS Form 1099purposes. That individual’s NPI is reported in NM109, and the individual’s TIN must bereported in the REF segment of Loop ID-2010AA.The individual’s NPI must be reportedwhen the individual provider is eligible for an NPI.

Prior to the NPI compliance date, proprietary identifiers necessary for the receiver toidentify the Billing Provider entity are to be reported in the REF segment of LoopID-2010BB Payer Name. The TIN of the Billing Provider, used for IRS Form 1099purposes, must be reported in the REF segment of Loop ID-2010AA Billing Provider.

When the Billing Provider is an atypical provider, the Billing Provider should be the legalentity. However, willing trading partners may agree upon varying definitions. Proprietaryor legacy identifiers necessary for the trading partner to identify the entity are to bereported in the REF segment of Loop ID-2010BB Payer Name. The TIN, used for IRSForm 1099 purposes, must be reported in the REF segment of Loop ID-2010AA BillingProvider.

1.11 Coding of Drugs in the 837 ClaimThis section provides guidance on the coding of drug claims under HIPAA asaccomplished in the 2400 and 2410 loops. For home infusion therapy care claims thatinclude the drugs, biologics, and nutrition components of the total home infusion therapyencounters, refer to the 837 Health Care Claim: Institutional implementation guide.

Regarding format, although National Drug Code (NDC) numbers may have differentformats, all may be mapped to the 5-4-2 format used in this implementation guide, for

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Proprietary

example 12345-6789-01. NDC numbers are to be reported as an 11 character datastream with no separators. In other words, the hyphens are to be suppressed. HCPCScodes are always five characters in length.

1.11.1 Single Drug BillingAn 837 for a single drug will have one 2400 loop with the HCPCS code in SV202-2 andthe associated units in SV205. When required by situational rules, the 2410 loop is sentwith the NDC number in LIN03 and the associated quantity in CTP04. Loop ID-2410REF02 contains a prescription number when the drug is provided under prescription.

1.11.2 Compound Drug BillingAn 837 for a multiple ingredient compound will have one 2400 loop for each ingredientwith the HCPCS code in SV202-2, the provider’s charge for that ingredient in SV203,and the associated units in SV205. When required by situational rules, the 2410 loop issent with the NDC number in LIN03 with the associated quantity in CTP04. Loop ID-2410REF02 must have the same prescription number, or the same linkage number if providedwithout a prescription, for each ingredient of the compound to enable the payer todifferentiate and link the ingredients to a single compound.

1.12 Additional Instructions andConsiderations

1.12.1 Individuals with one Legal NameIn those situations where an individual has only one legal name, report that name in thelast name data element of the NM1 segment, specifically the NM103.The first and middlename data elements for that NM1 segment are then not used. This guideline is true forall loops containing an NM1 segment that may identify an individual.

1.12.2 Rejecting Claims Based on the Inclusion ofSituational Data

This implementation guide contains a number of Situational Rules which state the elementor segment is required when a payer's adjudication is known to be impacted by thatinformation. These rules must not be construed as allowing the current payer to rejecta claim or transaction if the information is submitted but not used by that payer. The

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condition in these situational rules is based on a known impact to any potential payer'sadjudication.

The purpose is to enable proper adjudication for any potential downstream payers aswell as allow affected providers to collect and report information consistently for all tradingpartners when desired. As a result, the submitter is not restricted from sending theinformation to other payers in addition to the specific payer that has a known adjudicationimpact.

1.12.3 Multiple REF Segments with the same QualifierA repeat of a REF segment within the same loop is not allowed when the qualifier in theREF01 data element is the same. However, there is one important exception to this rule.Within the 837, there are data elements reported in Loop ID-2400 and the various 2420loops which are payer specific (for example: Referral Number, Prior Authorization Number,Provider Identifiers...). When these pieces of information are reported, the compositedata element in REF04 is used to identify the associated payer. In all cases, the reporteddata belongs to the destination payer when REF04 is not used. When REF04 is used,the value reported in the first component (REF04-1) equals 2U. This qualifier indicatesthe value reported in the following component (REF04-2) is a payer identifier.This payeridentifier "links" to one of the payer identifiers found in Loop ID-2330B NM109.

1.12.4 Provider Tax IDsFor purposes of this implementation, the Billing Provider is the provider or providerorganization to which payment is intended to be made. This payment is included in theprovider's 1099 reporting. The Employer Identification Number (EIN) or Social SecurityNumber (SSN) for the billing provider is only reported in the Billing Provider TaxIdentification REF segment in Loop ID-2010AA Billing Provider. The EIN and SSNqualifiers are not valid in any provider REF segments other than the 2010AA BillingProvider loop. Other reference qualifiers must be used in the REF segments in thoseloops to provide identifying information, such as "G2" for Provider's Commercial Number.

1.12.5 Claim and Line Redundant InformationThis implementation guide supports the reporting of some information at the claim andthe service levels to enable the reporting of individual line specific information. The linelevel usage notes for these pieces of information state “Required when different thanthat reported at the claim level. If not required by this implementation guide, do not send.”This wording results in the potential for misinterpretation resulting in unintended rigidity.These usage notes, as written with the “do not send” statement, should be applied as

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establishing the conditions when a submitter must send, and when a submitter is notrequired to send, the line level information. This “do not send” statement does notestablish situations where a receiver is allowed, or is required, to reject a claim. Thatwould be placing an unnecessary burden on the sender. The appropriate action by areceiver is to “ignore, but don’t reject” this redundant claim/line information. If redundantdata segments or elements are reported but are not necessary for the receiver withintheir application, the receiver ignores the information that is not needed. The presenceof the unneeded information must not cause the transaction to be rejected.

These usage notes do not permit a receiver to request or require the redundant line leveldata. Sending the redundant data is strictly at the submitter’s discretion.

An example of this would be Rendering Provider information that is supported in the2310 and 2420 loops of the Institutional, Professional, and Dental implementation guides.The same Rendering Provider information might be reported at both the claim and linelevels. This situation would not alter the payment of that claim nor complicate theadjudication algorithms. Consequently, rejecting any claims because of the presence ofthis redundant data would unnecessarily burden the provider community and furthercomplicate the claim process.

Other examples exist in the claim implementation guides where the business casesopen up the possibility for redundant data to be reported. For all such situations, theprinciple is to “ignore, but don’t reject”.

1.12.6 Inpatient and Outpatient DesignationThe determination of what constitutes an Inpatient or Outpatient claim is defined in theexternal code set developed by the National Uniform Billing Committee in its DataSpecifications Manual (UB Manual) beginning with UB-04. General guidelines arecontained in the Type of Bill section of the UB Manual. Inpatient and Outpatient claimsare distinguished by Type of Bill and other factors. Certain bill types are designated forinpatient use while others are designated for outpatient reporting. Exceptions to thegeneral rules are documented with reference to the specific data elements affected.

1.12.7 Trading Partner AcknowledgmentsThe authors of this implementation guide strongly encourage submitters of this transactionto expect and require standard electronic acknowledgments from receivers.The authorsencourage receivers to expect and require submitters to have an operational capabilityto accept and take action on standard electronic acknowledgments.

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2 Transaction SetNOTESee Appendix B, Nomenclature, to review the transaction set structure, includingdescriptions of segments, data elements, levels, and loops.

2.1 Presentation ExamplesThe ASC X12 standards are generic. For example, multiple trading communitiesuse the same PER segment to specify administrative communication contacts.Each community decides which elements to use and which code values in thoseelements are applicable.

This implementation guide uses a format that depicts both the generalized stand-ard and the insurance industry-specific implementation. In this implementationguide, IMPLEMENTATION specifies the requirements for this implementation.X12 STANDARD is included as a reference only.

The transaction set presentation is comprised of two main sections with subsec-tions within the main sections:

2.3 Transaction Set Listing

There are two sub-sections under this general title. The first sub-sectionconcerns this implementation of a generic X12 transaction set. The second sub-section concerns the generic X12 standard itself.

IMPLEMENTATION

This section lists the levels, loops, and segments contained in thisimplementation. It also serves as an index to the segment detail.

STANDARD

This section is included as a reference.

2.4 Segment Detail

There are three sub-sections under this general title. This section repeats once for each segment used in this implementation providing segment specific detail and X12 standard detail.

SEGMENT DETAIL

This section is included as a reference.

DIAGRAM

This section is included as a reference. It provides a pictorial view of the standard and shows which elements are used in this implementation.

ELEMENT DETAIL

This section specifies the implementation details of each data element.


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These illustrations (Figures 2.1 through 2.5) are examples and are not extractedfrom the Section 2 detail in this implementation guide. Annotated illustrations, pre-sented below in the same order they appear in this implementation guide, de-scribe the format of the transaction set that follows.


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IMPLEMENTATION

8XX Insurance Transaction Set

Table 1 - HeaderPAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

53 0100 ST Transaction Set Header R 154 0200 BPR Financial Information R 160 0400 TRN Reassociation Key R 162 0500 CUR Non-US Dollars Currency S 165 0600 REF Receiver ID S 166 0600 REF Version Number S 168 0700 DTM Production Date S 1

PAYER NAME 1 70 0800 N1 Payer Name R 172 1000 N3 Payer Address S 175 1100 N4 Payer City, State, Zip S 176 1200 REF Additional Payer Reference Number S 178 1300 PER Payer Contact S 1

PAYEE NAME 1 79 0800 N1 Payee Name R 181 1000 N3 Payee Address S 182 1100 N4 Payee City, State, Zip S 184 1200 REF Payee Additional Reference Number S >1

Each segment is assigned anindustry specific name. Notused segments do not appear

Each loop is assigned anindustry specific name

Indicates thatthis section isthe implementationand not the standard

Segmentrepeats andloop repeatsreflect actualusage

R=RequiredS=Situational

Individual segments and entire loops are repeated Position Numbers and Segment IDs retain their X12 values

Figure 2.1. Transaction Set Key — Implementation

STANDARD

8XX Insurance Transaction SetFunctional Group ID: XX

This Draft Standard for Trial Use contains the format and establishes the data contents ofthe Insurance Transaction Set (8XX) within the context of the Electronic Data Interchange(EDI) environment.

Table 1 - HeaderPOS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

0100 ST Transaction Set Header M 10200 BPR Beginning Segment M 10300 NTE Note/Special Instruction O >10400 TRN Trace O 1

Indicates thatthis section is identicalto the ASC X12 standard

See Appendix B.1, ASCX12 Nomenclature for acomplete description ofthe standard

Figure 2.2. Transaction Set Key — Standard


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SEGMENT DETAIL

NM1 - PATIENT NAMEX12 Segment Name: Individual or Organizational Name

X12 Purpose: To supply the full name of an individual or organizational entity

X12 Syntax: 1. P0809If either NM108 or NM109 is present, then the other is required.

2. C1110If NM111 is present, then NM110 is required.


Loop: 2100B — PATIENT NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

Situational Rule: Required when the patient is different from the insured. If not required by thisimplementation guide, do not send.

TR3 Notes: 1. Any necessary identification number must be provided in NM109.

TR3 Example: NM1✽ QC✽ 1✽ Shepard✽ Sam✽ A✽✽✽ 34✽ 452114586~

Industryusage

Industry assignedSegment Name

Industry SegmentRepeat

IndustryNotes

Example

Industry Loop Repeat

Industry assignedLoop ID and LoopName

See sectionB.1.1.3.8 fora descriptionof thesevalues

SituationalRule

Figure 2.3. Segment Key — Implementation

DIAGRAM

N101 98 N102 93 N103 66 N104 67 N105 706 N106 98

N1 ✽ Entity IDCode

✽ Name ✽ ID CodeQualifier

✽ IDCode

✽ EntityRelat Code

✽ Entity IDCode

~

M 1 ID 2/2 X 1 AN 1/35 X 1 ID 1/2 X 1 AN 2/20 O 1 ID 2/2 O 1 ID 2/2

Segment ID

RequirementDesignator

Minimum/Maximum Length

Indicates aRequired Element

Indicates a NotUsed Element

ElementDelimiter

AbbreviatedElement Name

DataType

SegmentTerminator

ElementRepeat

Indicates aSituational Element

Figure 2.4. Segment Key — Diagram


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ELEMENT DETAIL

USAGEREF.DES.

DATAELEMENT NAME ATTRIBUTES

REQUIRED SVC01 C003 COMPOSITE MEDICAL PROCEDUREIDENTIFIER

M 1

To identify a medical procedure by its standardized codes andapplicable modifiers

124 Use the Primary Payer’s adjudicated Medical Procedure Code.

REQUIRED SVC01 - 1 235 Product/Service ID Qualifier M ID 2/2Code identifying the type/source of the descriptive numberused in Product/Service ID (234)

IMPLEMENTATION NAME: Product or Service ID Qualifier

127 The value in SVC01-1 qualifies the values in SVC01-2,SVC01-3, SVC01-4, SVC01-5, and SVC01-6.

CODE DEFINITION

AD American Dental Association CodesCODE SOURCE 135: American Dental Association

HP Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate CodeCODE SOURCE 716: Health Insurance ProspectivePayment System (HIPPS) Rate Code for SkilledNursing Facilities

REQUIRED SVC01 - 2 234 Product/Service ID M AN 1/48Identifying number for a product or service

NOT USED SVC01 - 3 1339 Procedure Modifier O AN 2/2NOT USED SVC01 - 4 1339 Procedure Modifier O AN 2/2NOT USED SVC01 - 5 1339 Procedure Modifier O AN 2/2NOT USED SVC01 - 6 1339 Procedure Modifier O AN 2/2NOT USED SVC01 - 7 352 Description O AN 1/80REQUIRED SVC02 782 Monetary Amount M 1 R 1/18

Monetary amount

SEMANTIC: SVC02 is the submitted service charge.

1000112 This value can not be negative.NOT USED SVC03 782 Monetary Amount O 1 R 1/18SITUATIONAL SVC04 234 Product/Service ID O 1 AN 1/48

Identifying number for a product or service

SEMANTIC: SVC04 is the National Uniform Billing Committee Revenue Code.

SITUATIONAL RULE: Required when an NUBC revenue code wasconsidered during adjudication in addition to a procedure codealready identified in SVC01. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: National Uniform Billing Committee RevenueCode

Selected Code Values

Industry Note

Industry Usage:See the followingpage for completedescriptions

Data ElementNumber

Element Repeat

Situational Rule

Reference Designator

See Appendix A forexternal code sourcereference

CompositeNumber

Implementation NameSee Appendix E fordefinition

X12 Semantic Note

Figure 2.5. Segment Key — Element Summary


MAY 2006 51

2.2 Implementation Usage

2.2.1 Industry UsageIndustry Usage describes when loops, segments, and elements are to be sentwhen complying with this implementation guide. The three choices for Usage arerequired, not used, and situational. To avoid confusion, these are named differ-ently than the X12 standard Condition Designators (mandatory, optional, and rela-tional).

Required This loop/segment/element must always be sent.

Required segments in Situational loops only occur when the loopis used.

Required elements in Situational segments only occur when thesegment is used.

Required component elements in Situational composite ele-ments only occur when the composite element is used.

Not Used This element must never be sent.

Situational Use of this loop/segment/element varies, depending on data con-tent and business context as described in the defining rule. Thedefining rule is documented in a Situational Rule attached to theitem.

There are two forms of Situational Rules.

The first form is “Required when <explicit condition statement>.If not required by this implementation guide, may be provided atthe sender’s discretion, but cannot be required by the receiver.”The data qualified by such a situational rule cannot be requiredor requested by the receiver, transmission of this data is solely atthe sender’s discretion.

The alternative form is “Required when <explicit condition state-ment>. If not required by this implementation guide, do notsend.” The data qualified by such a situational rule cannot besent except as described in the explicit condition statement.


52 MAY 2006

2.2.1.1 Transaction Compliance Related to Industry Usage

A transmitted transaction complies with an implementation guide when it satisfiesthe requirements as defined within the implementation guide. The presence or ab-sence of an item (loop, segment, or element) complies with the industry usagespecified by this implementation guide according to the following table.

Industry Usage

BusinessCondition

isItem

is

TransactionComplies with

ImplementationGuide?

RequiredN/A

Sent YesNot Sent No

Not UsedN/A

Sent NoNot Sent Yes

Situational (Required when <explicitcondition statement>. If not required bythis implementation guide, may be

TrueSent Yes

Not Sent No

provided at the sender’s discretion, butcannot be required by the receiver.) Not True

Sent Yes

Not Sent YesSituational (Required when <explicitcondition statement>. If not required bythis implementation guide, do not send.)

TrueSent Yes

Not Sent No

Not TrueSent No

Not Sent Yes

This table specifies how an entity is to evaluate a transmitted transaction for com-pliance with industry usage. It is not intended to require or imply that the receivermust reject non-compliant transactions. The receiver will handle non-complianttransactions based on its business process and any applicable regulations.

2.2.2 LoopsLoop requirements depend on the context or location of the loop within the trans-action. See Appendix B for more information on loops.

• A nested loop can be used only when the associated higher level loop is used.

• The usage of a loop is the same as the usage of its beginning segment.

• If a loop’s beginning segment is Required, the loop is Required and must oc-cur at least once unless it is nested in a loop that is not being used.

• If a loop’s beginning segment is Situational, the loop is Situational.

• Subsequent segments within a loop can be sent only when the beginning seg-ment is used.

• Required segments in Situational loops occur only when the loop is used.


MAY 2006 53


54 MAY 2006

2.3 Transaction Set Listing

2.3.1 Implementation

This section lists the levels, loops, and segments contained in this implementa-tion. It also serves as an index to the segment detail. Refer to section 2.1 Presen-tation Examples for detailed information on the components of theImplementation section.

005010X223 • 837ASC X12N • INSURANCE SUBCOMMITTEETECHNICAL REPORT • TYPE 3

MAY 2006 55

005010X223 • 837

MAY 31, 2006IMPLEMENTATION

837 Health Care Claim: Institutional

Table 1 - Header

PAGE # POS. # SEG. ID NAME USAGE REPEAT LOOP REPEAT

67 0050 ST Transaction Set Header R 168 0100 BHT Beginning of Hierarchical Transaction R 1

LOOP ID - 1000A SUBMITTER NAME 1 71 0200 NM1 Submitter Name R 173 0450 PER Submitter EDI Contact Information R 2

LOOP ID - 1000B RECEIVER NAME 1 76 0200 NM1 Receiver Name R 1

Table 2 - Billing Provider Detail


LOOP ID - 2000A BILLING PROVIDERHIERARCHICAL LEVEL

>1

78 0010 HL Billing Provider Hierarchical Level R 180 0030 PRV Billing Provider Specialty Information S 181 0100 CUR Foreign Currency Information S 1

LOOP ID - 2010AA BILLING PROVIDER NAME 1 84 0150 NM1 Billing Provider Name R 187 0250 N3 Billing Provider Address R 188 0300 N4 Billing Provider City, State, ZIP Code R 190 0350 REF Billing Provider Tax Identification R 191 0400 PER Billing Provider Contact Information S 2

LOOP ID - 2010AB PAY-TO ADDRESS NAME 1 94 0150 NM1 Pay-to Address Name S 196 0250 N3 Pay-to Address - ADDRESS R 197 0300 N4 Pay-To Address City, State, ZIP Code R 1

LOOP ID - 2010AC PAY-TO PLAN NAME 1 99 0150 NM1 Pay-To Plan Name S 1101 0250 N3 Pay-to Plan Address R 1102 0300 N4 Pay-To Plan City, State, ZIP Code R 1104 0350 REF Pay-to Plan Secondary Identification S 1106 0350 REF Pay-To Plan Tax Identification Number R 1

ASC X12N • INSURANCE SUBCOMMITTEE005010X223 • 837 TECHNICAL REPORT • TYPE 3

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Table 2 - Subscriber Detail


LOOP ID - 2000B SUBSCRIBER HIERARCHICALLEVEL

>1

107 0010 HL Subscriber Hierarchical Level R 1109 0050 SBR Subscriber Information R 1

LOOP ID - 2010BA SUBSCRIBER NAME 1 112 0150 NM1 Subscriber Name R 1115 0250 N3 Subscriber Address S 1116 0300 N4 Subscriber City, State, ZIP Code R 1118 0320 DMG Subscriber Demographic Information S 1120 0350 REF Subscriber Secondary Identification S 1121 0350 REF Property and Casualty Claim Number S 1

LOOP ID - 2010BB PAYER NAME 1 122 0150 NM1 Payer Name R 1124 0250 N3 Payer Address S 1125 0300 N4 Payer City, State, ZIP Code R 1127 0350 REF Payer Secondary Identification S 3129 0350 REF Billing Provider Secondary Identification S 1

Table 2 - Patient Detail

For purposes of this documentation, the claim detail information is presented only in the dependent level.Specific claim detail information can be given in either the subscriber or the dependent hierarchical level.Because of this the claim information is said to “float.” Claim information is positioned in the same hierarchicallevel that describes its owner-participant, either the subscriber or the dependent. In other words, the claiminformation, loop 2300, is placed following loop 2010BB in the subscriber hierarchical level when the patient isthe subscriber, or it is placed at the patient/dependent hierarchical level when the patient is the dependent ofthe subscriber as shown here. When the patient is the subscriber, loops 2000C and 2010CA are not sent. See1.4.3.2.2.1, HL Segment, for details.


LOOP ID - 2000C PATIENT HIERARCHICAL LEVEL >1 131 0010 HL Patient Hierarchical Level S 1133 0070 PAT Patient Information R 1

LOOP ID - 2010CA PATIENT NAME 1 135 0150 NM1 Patient Name R 1137 0250 N3 Patient Address R 1138 0300 N4 Patient City, State, ZIP Code R 1140 0320 DMG Patient Demographic Information R 1142 0350 REF Property and Casualty Claim Number S 1

LOOP ID - 2300 CLAIM INFORMATION 100 143 1300 CLM Claim Information R 1149 1350 DTP Discharge Hour S 1150 1350 DTP Statement Dates R 1151 1350 DTP Admission Date/Hour S 1152 1350 DTP Date - Repricer Received Date S 1153 1400 CL1 Institutional Claim Code R 1154 1550 PWK Claim Supplemental Information S 10158 1600 CN1 Contract Information S 1160 1750 AMT Patient Estimated Amount Due S 1161 1800 REF Service Authorization Exception Code S 1

ASC X12N • INSURANCE SUBCOMMITTEETECHNICAL REPORT • TYPE 3 005010X223 • 837

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163 1800 REF Referral Number S 1164 1800 REF Prior Authorization S 1166 1800 REF Payer Claim Control Number S 1167 1800 REF Repriced Claim Number S 1168 1800 REF Adjusted Repriced Claim Number S 1169 1800 REF Investigational Device Exemption Number S 5170 1800 REF Claim Identifier For Transmission Intermediaries S 1172 1800 REF Auto Accident State S 1173 1800 REF Medical Record Number S 1174 1800 REF Demonstration Project Identifier S 1175 1800 REF Peer Review Organization (PRO) Approval Number S 1176 1850 K3 File Information S 10178 1900 NTE Claim Note S 10180 1900 NTE Billing Note S 1181 2200 CRC EPSDT Referral S 1184 2310 HI Principal Diagnosis R 1187 2310 HI Admitting Diagnosis S 1189 2310 HI Patient’s Reason For Visit S 1193 2310 HI External Cause of Injury S 1218 2310 HI Diagnosis Related Group (DRG) Information S 1220 2310 HI Other Diagnosis Information S 2239 2310 HI Principal Procedure Information S 1242 2310 HI Other Procedure Information S 2258 2310 HI Occurrence Span Information S 2271 2310 HI Occurrence Information S 2284 2310 HI Value Information S 2294 2310 HI Condition Information S 2304 2310 HI Treatment Code Information S 2313 2410 HCP Claim Pricing/Repricing Information S 1

LOOP ID - 2310A ATTENDING PROVIDER NAME 1 319 2500 NM1 Attending Provider Name S 1322 2550 PRV Attending Provider Specialty Information S 1324 2710 REF Attending Provider Secondary Identification S 4

LOOP ID - 2310B OPERATING PHYSICIAN NAME 1 326 2500 NM1 Operating Physician Name S 1329 2710 REF Operating Physician Secondary Identification S 4

LOOP ID - 2310C OTHER OPERATING PHYSICIANNAME

1

331 2500 NM1 Other Operating Physician Name S 1334 2710 REF Other Operating Physician Secondary Identification S 4

LOOP ID - 2310D RENDERING PROVIDER NAME 1 336 2500 NM1 Rendering Provider Name S 1339 2710 REF Rendering Provider Secondary Identification S 4

LOOP ID - 2310E SERVICE FACILITY LOCATIONNAME

1

341 2500 NM1 Service Facility Location Name S 1344 2650 N3 Service Facility Location Address R 1345 2700 N4 Service Facility Location City, State, ZIP Code R 1347 2710 REF Service Facility Location Secondary Identification S 3

LOOP ID - 2310F REFERRING PROVIDER NAME 1 349 2500 NM1 Referring Provider Name S 1352 2710 REF Referring Provider Secondary Identification S 3

LOOP ID - 2320 OTHER SUBSCRIBER INFORMATION 10 354 2900 SBR Other Subscriber Information S 1358 2950 CAS Claim Level Adjustments S 5


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364 3000 AMT Coordination of Benefits (COB) Payer Paid Amount S 1365 3000 AMT Remaining Patient Liability S 1366 3000 AMT Coordination of Benefits (COB) Total Non-Covered

AmountS 1

367 3100 OI Other Insurance Coverage Information R 1369 3150 MIA Inpatient Adjudication Information S 1374 3200 MOA Outpatient Adjudication Information S 1

LOOP ID - 2330A OTHER SUBSCRIBER NAME 1 377 3250 NM1 Other Subscriber Name R 1380 3320 N3 Other Subscriber Address S 1381 3400 N4 Other Subscriber City, State, ZIP Code R 1383 3550 REF Other Subscriber Secondary Identification S 2

LOOP ID - 2330B OTHER PAYER NAME 1 384 3250 NM1 Other Payer Name R 1386 3320 N3 Other Payer Address S 1387 3400 N4 Other Payer City, State, ZIP Code R 1389 3500 DTP Claim Check or Remittance Date S 1390 3550 REF Other Payer Secondary Identifier S 2392 3550 REF Other Payer Prior Authorization Number S 1393 3550 REF Other Payer Referral Number S 1394 3550 REF Other Payer Claim Adjustment Indicator S 1395 3550 REF Other Payer Claim Control Number S 1

LOOP ID - 2330C OTHER PAYER ATTENDINGPROVIDER

1

396 3250 NM1 Other Payer Attending Provider S 1398 3550 REF Other Payer Attending Provider Secondary Identification R 4

LOOP ID - 2330D OTHER PAYER OPERATINGPHYSICIAN

1

400 3250 NM1 Other Payer Operating Physician S 1402 3550 REF Other Payer Operating Physician Secondary Identification R 4

LOOP ID - 2330E OTHER PAYER OTHER OPERATINGPHYSICIAN

1

404 3250 NM1 Other Payer Other Operating Physician S 1406 3550 REF Other Payer Other Operating Physician Secondary

IdentificationR 4

LOOP ID - 2330F OTHER PAYER SERVICE FACILITYLOCATION

1

408 3250 NM1 Other Payer Service Facility Location S 1410 3550 REF Other Payer Service Facility Location Secondary

IdentificationR 3

LOOP ID - 2330G OTHER PAYER RENDERINGPROVIDER NAME

1

412 3250 NM1 Other Payer Rendering Provider Name S 1414 3550 REF Other Payer Rendering Provider Secondary Identification R 4

LOOP ID - 2330H OTHER PAYER REFERRINGPROVIDER

1

416 3250 NM1 Other Payer Referring Provider S 1418 3550 REF Other Payer Referring Provider Secondary Identification R 3

LOOP ID - 2330I OTHER PAYER BILLING PROVIDER 1 420 3250 NM1 Other Payer Billing Provider S 1422 3550 REF Other Payer Billing Provider Secondary Identification R 2

LOOP ID - 2400 SERVICE LINE NUMBER 999 423 3650 LX Service Line Number R 1424 3750 SV2 Institutional Service Line R 1429 4200 PWK Line Supplemental Information S 10


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433 4550 DTP Date - Service Date S 1435 4700 REF Line Item Control Number S 1437 4700 REF Repriced Line Item Reference Number S 1438 4700 REF Adjusted Repriced Line Item Reference Number S 1439 4750 AMT Service Tax Amount S 1440 4750 AMT Facility Tax Amount S 1441 4850 NTE Third Party Organization Notes S 1442 4920 HCP Line Pricing/Repricing Information S 1

LOOP ID - 2410 DRUG IDENTIFICATION 1 449 4930 LIN Drug Identification S 1452 4940 CTP Drug Quantity R 1454 4950 REF Prescription or Compound Drug Association Number S 1

LOOP ID - 2420A OPERATING PHYSICIAN NAME 1 456 5000 NM1 Operating Physician Name S 1459 5250 REF Operating Physician Secondary Identification S 20

LOOP ID - 2420B OTHER OPERATING PHYSICIANNAME

1

461 5000 NM1 Other Operating Physician Name S 1464 5250 REF Other Operating Physician Secondary Identification S 20

LOOP ID - 2420C RENDERING PROVIDER NAME 1 466 5000 NM1 Rendering Provider Name S 1469 5250 REF Rendering Provider Secondary Identification S 20

LOOP ID - 2420D REFERRING PROVIDER NAME 1 471 5000 NM1 Referring Provider Name S 1474 5250 REF Referring Provider Secondary Identification S 20

LOOP ID - 2430 LINE ADJUDICATION INFORMATION 15 476 5400 SVD Line Adjudication Information S 1480 5450 CAS Line Adjustment S 5486 5500 DTP Line Check or Remittance Date R 1487 5505 AMT Remaining Patient Liability S 1488 5550 SE Transaction Set Trailer R 1


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2.3.2 X12 Standard

This section is included as a reference. The implementation guide reference clari-fies actual usage. Refer to section 2.1 Presentation Examples for detailed infor-mation on the components of the X12 Standard section.


MAY 2006 61

STANDARD

837 Health Care ClaimFunctional Group ID: HC

This X12 Transaction Set contains the format and establishes the data contents of the HealthCare Claim Transaction Set (837) for use within the context of an Electronic Data Interchange(EDI) environment. This transaction set can be used to submit health care claim billinginformation, encounter information, or both, from providers of health care services to payers,either directly or via intermediary billers and claims clearinghouses. It can also be used totransmit health care claims and billing payment information between payers with differentpayment responsibilities where coordination of benefits is required or between payers andregulatory agencies to monitor the rendering, billing, and/or payment of health care serviceswithin a specific health care/insurance industry segment.

For purposes of this standard, providers of health care products or services may include entitiessuch as physicians, hospitals and other medical facilities or suppliers, dentists, and pharmacies,and entities providing medical information to meet regulatory requirements. The payer refers to athird party entity that pays claims or administers the insurance product or benefit or both. Forexample, a payer may be an insurance company, health maintenance organization (HMO),preferred provider organization (PPO), government agency (Medicare, Medicaid, Civilian Healthand Medical Program of the Uniformed Services (CHAMPUS), etc.) or an entity such as a thirdparty administrator (TPA) or third party organization (TPO) that may be contracted by one ofthose groups. A regulatory agency is an entity responsible, by law or rule, for administering andmonitoring a statutory benefits program or a specific health care/insurance industry segment.

Table 1 - Header

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

0050 ST Transaction Set Header M 10100 BHT Beginning of Hierarchical Transaction M 10150 REF Reference Information O 3

LOOP ID - 1000 10 0200 NM1 Individual or Organizational Name O 10250 N2 Additional Name Information O 20300 N3 Party Location O 20350 N4 Geographic Location O 10400 REF Reference Information O 20450 PER Administrative Communications Contact O 2

Table 2 - Detail

PAGE # POS. # SEG. ID NAME REQ. DES. MAX USE LOOP REPEAT

LOOP ID - 2000 >1 0010 HL Hierarchical Level M 10030 PRV Provider Information O 10050 SBR Subscriber Information O 10070 PAT Patient Information O 10090 DTP Date or Time or Period O 50100 CUR Currency O 1

LOOP ID - 2010 10 0150 NM1 Individual or Organizational Name O 10200 N2 Additional Name Information O 2


62 MAY 2006

0250 N3 Party Location O 20300 N4 Geographic Location O 10320 DMG Demographic Information O 10350 REF Reference Information O 200400 PER Administrative Communications Contact O 2

LOOP ID - 2300 100 1300 CLM Health Claim O 11350 DTP Date or Time or Period O 1501400 CL1 Claim Codes O 11450 DN1 Orthodontic Information O 11500 DN2 Tooth Summary O 351550 PWK Paperwork O 101600 CN1 Contract Information O 11650 DSB Disability Information O 11700 UR Peer Review Organization or Utilization Review O 11750 AMT Monetary Amount Information O 401800 REF Reference Information O 301850 K3 File Information O 101900 NTE Note/Special Instruction O 201950 CR1 Ambulance Certification O 12000 CR2 Chiropractic Certification O 12050 CR3 Durable Medical Equipment Certification O 12100 CR4 Enteral or Parenteral Therapy Certification O 32150 CR5 Oxygen Therapy Certification O 12160 CR6 Home Health Care Certification O 12190 CR8 Pacemaker Certification O 92200 CRC Conditions Indicator O 1002310 HI Health Care Information Codes O 252400 QTY Quantity Information O 102410 HCP Health Care Pricing O 1

LOOP ID - 2305 6 2420 CR7 Home Health Treatment Plan Certification O 12430 HSD Health Care Services Delivery O 12

LOOP ID - 2310 9 2500 NM1 Individual or Organizational Name O 12550 PRV Provider Information O 12600 N2 Additional Name Information O 22650 N3 Party Location O 22700 N4 Geographic Location O 12710 REF Reference Information O 202750 PER Administrative Communications Contact O 2

LOOP ID - 2320 10 2900 SBR Subscriber Information O 12950 CAS Claims Adjustment O 993000 AMT Monetary Amount Information O 153050 DMG Demographic Information O 13100 OI Other Health Insurance Information O 13150 MIA Medicare Inpatient Adjudication O 13200 MOA Medicare Outpatient Adjudication O 1

LOOP ID - 2330 10 3250 NM1 Individual or Organizational Name O 13300 N2 Additional Name Information O 23320 N3 Party Location O 23400 N4 Geographic Location O 13450 PER Administrative Communications Contact O 2


MAY 2006 63

3500 DTP Date or Time or Period O 93550 REF Reference Information O >1

LOOP ID - 2400 >1 3650 LX Transaction Set Line Number O 13700 SV1 Professional Service O 13750 SV2 Institutional Service O 13800 SV3 Dental Service O 13820 TOO Tooth Identification O 323850 SV4 Drug Service O 14000 SV5 Durable Medical Equipment Service O 14050 SV6 Anesthesia Service O 14100 SV7 Drug Adjudication O 14150 HI Health Care Information Codes O 254200 PWK Paperwork O 104250 CR1 Ambulance Certification O 14300 CR2 Chiropractic Certification O 54350 CR3 Durable Medical Equipment Certification O 14400 CR4 Enteral or Parenteral Therapy Certification O 34450 CR5 Oxygen Therapy Certification O 14500 CRC Conditions Indicator O 34550 DTP Date or Time or Period O 154600 QTY Quantity Information O 54620 MEA Measurements O 204650 CN1 Contract Information O 14700 REF Reference Information O 304750 AMT Monetary Amount Information O 154800 K3 File Information O 104850 NTE Note/Special Instruction O 104880 PS1 Purchase Service O 14900 IMM Immunization Status O >14910 HSD Health Care Services Delivery O 14920 HCP Health Care Pricing O 1

LOOP ID - 2410 >1 4930 LIN Item Identification O 14940 CTP Pricing Information O 14950 REF Reference Information O 1

LOOP ID - 2420 10 5000 NM1 Individual or Organizational Name O 15050 PRV Provider Information O 15100 N2 Additional Name Information O 25140 N3 Party Location O 25200 N4 Geographic Location O 15250 REF Reference Information O 205300 PER Administrative Communications Contact O 2

LOOP ID - 2430 >1 5400 SVD Service Line Adjudication O 15450 CAS Claims Adjustment O 995500 DTP Date or Time or Period O 95505 AMT Monetary Amount Information O 20

LOOP ID - 2440 >1 5510 LQ Industry Code Identification O 15520 FRM Supporting Documentation M 995550 SE Transaction Set Trailer M 1


64 MAY 2006

NOTES:

1/0200 Loop 1000 contains submitter and receiver information. If any intermediary receivers change or add data in any way, then

they add an occurrence to the loop as a form of identification. The added loop occurrence must be the last occurrence of

the loop.

2/0150 Loop 2010 contains information about entities that apply to all claims in loop 2300. For example, these entities may in-

clude billing provider, pay-to provider, insurer, primary administrator, contract holder, or claimant.

2/1950 The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because

certifications can be submitted for all services on a claim or for individual services. Certification information at the claim

level applies to all service lines of the claim, unless overridden by certification information at the service line level.

2/2500 Loop 2310 contains information about the rendering, referring, or attending provider.

2/2900 Loop 2320 contains insurance information about: paying and other Insurance Carriers for that Subscriber, Subscriber of

the Other Insurance Carriers, School or Employer Information for that Subscriber.

2/3250 Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

2/3650 Loop 2400 contains Service Line information.

2/4250 The CR1 through CR5 and CRC certification segments appear on both the claim level and the service line level because

certifications can be submitted for all services on a claim or for individual services. Certification information at the claim

level applies to all service lines of the claim, unless overridden by certification information at the service line level.

2/4930 Loop 2410 contains compound drug components, quantities and prices.

2/5000 Loop 2420 contains information about the rendering, referring, or attending provider on a service line level. These seg-

ments override the information in the claim - level segments if the entity identifier codes in each NM1 segment are the

same.

2/5400 SVD01 identifies the payer which adjudicated the corresponding service line and must match DE 67 in the NM109 posi-

tion 325 for the payer.

2/5510 Loop 2440 provides certificate of medical necessity information for the procedure identified in SV101 in position 2/3700.

2/5520 FRM segment provides question numbers and responses for the questions on the medical necessity information form

identified in LQ position 551.


MAY 2006 65

2.4 837 - Segment DetailThis section specifies the segments, data elements, and codes for this implemen-tation. Refer to section 2.1 Presentation Examples for detailed information on thecomponents of the Segment Detail section.


66 MAY 2006

STTRANSACTION SET HEADER 005010X223 • 837 • STTRANSACTION SET HEADER

SEGMENT DETAIL

2 ST - TRANSACTION SET HEADERX12 Segment Name: Transaction Set Header

X12 Purpose: To indicate the start of a transaction set and to assign a control number

Segment Repeat: 1

Usage: REQUIRED

1272 TR3 Example: ST✽ 837✽ 987654✽ 005010X223~

DIAGRAM

ST01 143 ST02 329 ST03 1705

ST ✽ TS IDCode ✽ TS Control

Number ✽ Imple ConvReference ~

M 1 ID 3/3 M 1 AN 4/9 O 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED ST01 143 Transaction Set Identifier Code M 1 ID 3/3Code uniquely identifying a Transaction Set

SEMANTIC: The transaction set identifier (ST01) is used by the translation routinesof the interchange partners to select the appropriate transaction set definition(e.g., 810 selects the Invoice Transaction Set).

CODE DEFINITION

837 Health Care ClaimREQUIRED ST02 329 Transaction Set Control Number M 1 AN 4/9

Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction set

3 The Transaction Set Control Number in ST02 and SE02 must beidentical. The number must be unique within a specific interchange(ISA-IEA), but can repeat in other interchanges.

REQUIRED ST03 1705 Implementation Convention Reference O 1 AN 1/35Reference assigned to identify Implementation Convention

SEMANTIC: The implementation convention reference (ST03) is used by thetranslation routines of the interchange partners to select the appropriateimplementation convention to match the transaction set definition. When used,this implementation convention reference takes precedence over theimplementation reference specified in the GS08.

IMPLEMENTATION NAME: Version, Release, or Industry Identifier

4 This element must be populated with the guide identifier named inSection 1.2.

391 This field contains the same value as GS08. Some translatorproducts strip off the ISA and GS segments prior to application (ST-SE) processing. Providing the information from the GS08 at thislevel will ensure that the appropriate application mapping is used attranslation time.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • STTECHNICAL REPORT • TYPE 3 TRANSACTION SET HEADER

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BHTBEGINNING OF HIERARCHICAL TRANSACTION 005010X223 • 837 • BHTBEGINNING OF HIERARCHICAL TRANSACTION

SEGMENT DETAIL

394 BHT - BEGINNING OF HIERARCHICALTRANSACTION

X12 Segment Name: Beginning of Hierarchical Transaction

X12 Purpose: To define the business hierarchical structure of the transaction set and identifythe business application purpose and reference data, i.e., number, date, andtime

Segment Repeat: 1

Usage: REQUIRED

5 TR3 Notes: 1. The second example denotes the case where the entire transactionset contains ENCOUNTERS.

392 TR3 Example: BHT✽ 0019✽ 00✽ 0123✽ 20040618✽ 0932✽ CH~

393 TR3 Example: BHT✽ 0019✽ 00✽ 44445✽ 20040213✽ 0345✽ RP~

DIAGRAM

BHT01 1005 BHT02 353 BHT03 127 BHT04 373 BHT05 337 BHT06 640

BHT ✽ HierarchStruct Code ✽ TS Purpose

Code ✽ ReferenceIdent ✽ Date ✽ Time ✽ Transaction

Type Code ~

M 1 ID 4/4 M 1 ID 2/2 O 1 AN 1/50 O 1 DT 8/8 O 1 TM 4/8 O 1 ID 2/2

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED BHT01 1005 Hierarchical Structure Code M 1 ID 4/4Code indicating the hierarchical application structure of a transaction set thatutilizes the HL segment to define the structure of the transaction set

CODE DEFINITION

0019 Information Source, Subscriber, DependentREQUIRED BHT02 353 Transaction Set Purpose Code M 1 ID 2/2

Code identifying purpose of transaction set

7 BHT02 is intended to convey the electronic transmission status ofthe 837 batch contained in this ST-SE envelope. The terms“original” and “reissue” refer to the electronic transmission statusof the 837 batch, not the billing status.

CODE DEFINITION

00 Original

8 Original transmissions are transmissions whichhave never been sent to the receiver.

18 Reissue

9 If a transmission was disrupted and the receiverrequests a retransmission, the sender uses“Reissue” to indicate the transmission has beenpreviously sent.

005010X223 • 837 • BHT ASC X12N • INSURANCE SUBCOMMITTEEBEGINNING OF HIERARCHICAL TRANSACTION TECHNICAL REPORT • TYPE 3

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REQUIRED BHT03 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: BHT03 is the number assigned by the originator to identify thetransaction within the originator’s business application system.

IMPLEMENTATION NAME: Originator Application Transaction Identifier

10 The inventory file number of the transmission assigned by thesubmitter’s system. This number operates as a batch controlnumber.

11 This field is limited to 30 characters.

REQUIRED BHT04 373 Date O 1 DT 8/8Date expressed as CCYYMMDD where CC represents the first two digits of thecalendar year

SEMANTIC: BHT04 is the date the transaction was created within the businessapplication system.

IMPLEMENTATION NAME: Transaction Set Creation Date

12 This is the date that the original submitter created the claim filefrom their business application system.

REQUIRED BHT05 337 Time O 1 TM 4/8Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, orHHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =integer seconds (00-59) and DD = decimal seconds; decimal seconds areexpressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

SEMANTIC: BHT05 is the time the transaction was created within the businessapplication system.

IMPLEMENTATION NAME: Transaction Set Creation Time

13 This is the time that the original submitter created the claim filefrom their business application system.

REQUIRED BHT06 640 Transaction Type Code O 1 ID 2/2Code specifying the type of transaction

IMPLEMENTATION NAME: Claim Identifier

CODE DEFINITION

31 Subrogation Demand

395 The subrogation demand code is only for use bystate Medicaid agencies performing post paymentrecovery claiming with willing trading partners.NOTE: At the time of this writing, SubrogationDemand is not a HIPAA mandated use of the 837transaction.

CH Chargeable

396 Use CH when the transaction contains only fee forservice claims or claims with at least onechargeable line item. If it is not clear whether atransaction contains claims or capitatedencounters, or if the transaction contains a mix ofclaims and capitated encounters, use CH.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • BHTTECHNICAL REPORT • TYPE 3 BEGINNING OF HIERARCHICAL TRANSACTION

MAY 2006 69

tdrinkard

Cross-Out

RP Reporting

397 Use RP when the entire ST-SE envelope containsonly capitated encounters.Use RP when the transaction is being sent to anentity (usually not a payer or a normal providerpayer transmission intermediary) for purposes otherthan adjudication of a claim. Such an entity couldbe a state health data agency which is using the 837for health data reporting purposes.

005010X223 • 837 • BHT ASC X12N • INSURANCE SUBCOMMITTEEBEGINNING OF HIERARCHICAL TRANSACTION TECHNICAL REPORT • TYPE 3

70 MAY 2006

tdrinkard

Cross-Out

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 1000A • NM1SUBMITTER NAME

SEGMENT DETAIL

15 NM1 - SUBMITTER NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Loop 1000 contains submitter and receiver information. If any intermediaryreceivers change or add data in any way, then they add an occurrence tothe loop as a form of identification. The added loop occurrence must be thelast occurrence of the loop.




Loop: 1000A — SUBMITTER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

16 TR3 Notes: 1. The submitter is the entity responsible for the creation and formattingof this transaction.

14 TR3 Example: NM1✽ 41✽ 2✽ ABC SUBMITTER✽✽✽✽✽ 46✽ 999999999~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038

NM1 ✽ Entity IDCode ✽ Entity Type

Qualifier ✽ Name Last/Org Name ✽ Name

First ✽ NameMiddle ✽ Name

PrefixM 1 ID 2/3 M 1 ID 1/1 X 1 AN 1/60 O 1 AN 1/35 O 1 AN 1/25 O 1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

✽ NameSuffix ✽ ID Code

Qualifier ✽ IDCode ✽ Entity

Relat Code ✽ Entity IDCode ✽ Name Last/

Org Name ~

O 1 AN 1/10 X 1 ID 1/2 X 1 AN 2/80 X 1 ID 2/2 O 1 ID 2/3 O 1 AN 1/60

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED NM101 98 Entity Identifier Code M 1 ID 2/3Code identifying an organizational entity, a physical location, property or anindividual

CODE DEFINITION

41 Submitter

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 1000A • NM1TECHNICAL REPORT • TYPE 3 SUBMITTER NAME

MAY 2006 71

REQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1Code qualifying the type of entity

SEMANTIC: NM102 qualifies NM103.

CODE DEFINITION

1 Person

2 Non-Person EntityREQUIRED NM103 1035 Name Last or Organization Name X 1 AN 1/60

Individual last name or organizational name

SYNTAX: C1203

IMPLEMENTATION NAME: Submitter Last or Organization Name

SITUATIONAL NM104 1036 Name First O 1 AN 1/35Individual first name

17 SITUATIONAL RULE: Required when NM102 = 1 (person) and the personhas a first name. If not required by this implementation guide, donot send.

IMPLEMENTATION NAME: Submitter First Name

SITUATIONAL NM105 1037 Name Middle O 1 AN 1/25Individual middle name or initial

18 SITUATIONAL RULE: Required when NM102 = 1 (person) and the middlename or initial of the person is needed to identify the individual. Ifnot required by this implementation guide, do not send.

IMPLEMENTATION NAME: Submitter Middle Name or Initial

NOT USED NM106 1038 Name Prefix O 1 AN 1/10

NOT USED NM107 1039 Name Suffix O 1 AN 1/10

REQUIRED NM108 66 Identification Code Qualifier X 1 ID 1/2Code designating the system/method of code structure used for IdentificationCode (67)

SYNTAX: P0809

CODE DEFINITION

46 Electronic Transmitter Identification Number (ETIN)

19 Established by trading partner agreementREQUIRED NM109 67 Identification Code X 1 AN 2/80

Code identifying a party or other code

SYNTAX: P0809

IMPLEMENTATION NAME: Submitter Identifier

NOT USED NM110 706 Entity Relationship Code X 1 ID 2/2

NOT USED NM111 98 Entity Identifier Code O 1 ID 2/3

NOT USED NM112 1035 Name Last or Organization Name O 1 AN 1/60

005010X223 • 837 • 1000A • NM1 ASC X12N • INSURANCE SUBCOMMITTEESUBMITTER NAME TECHNICAL REPORT • TYPE 3

72 MAY 2006

PERADMINISTRATIVE COMMUNICATIONS CONTACT 005010X223 • 837 • 1000A • PERSUBMITTER EDI CONTACT INFORMATION

SEGMENT DETAIL

23 PER - SUBMITTER EDI CONTACTINFORMATION

X12 Segment Name: Administrative Communications Contact

X12 Purpose: To identify a person or office to whom administrative communications should bedirected

X12 Syntax: 1. P0304If either PER03 or PER04 is present, then the other is required.

2. P0506If either PER05 or PER06 is present, then the other is required.


Loop: 1000A — SUBMITTER NAME

Segment Repeat: 2

Usage: REQUIRED

24 TR3 Notes: 1. When the communication number represents a telephone number inthe United States and other countries using the North AmericanDialing Plan (for voice, data, fax, etc.), the communication numbermust always include the area code and phone number using theformat AAABBBCCCC where AAA is the area code, BBB is thetelephone number prefix, and CCCC is the telephone number.Therefore, the following telephone number (555) 555-1234 would berepresented as 5555551234. Do not submit long distance accessnumbers, such as “1”, in the telephone number. Telephoneextensions, when applicable, must be submitted in the next elementimmediately following the telephone number. When submittingtelephone extensions, only submit the numeric extension. Do notinclude data that indicates an extension, such as “ext” or “x-”.

26 2. The contact information in this segment identifies the person in thesubmitter organization who deals with data transmission issues. Ifdata transmission problems arise, this is the person to contact in thesubmitter organization.

27 3. There are 2 repetitions of the PER segment to allow for six possiblecombinations of communication numbers including extensions.

450 TR3 Example: PER✽ IC✽ JOHN SMITH✽ TE✽ 5555551234✽ EX✽ 123~

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 1000A • PERTECHNICAL REPORT • TYPE 3 SUBMITTER EDI CONTACT INFORMATION

MAY 2006 73

DIAGRAM

PER01 366 PER02 93 PER03 365 PER04 364 PER05 365 PER06 364

PER ✽ ContactFunct Code ✽ Name ✽ Comm

Number Qual ✽ CommNumber ✽ Comm

Number Qual ✽ CommNumber

M 1 ID 2/2 O 1 AN 1/60 X 1 ID 2/2 X 1 AN 1/256 X 1 ID 2/2 X 1 AN 1/256

PER07 365 PER08 364 PER09 443

✽ CommNumber Qual ✽ Comm

Number ✽ Contact InqReference ~

X 1 ID 2/2 X 1 AN 1/256 O 1 AN 1/20

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PER01 366 Contact Function Code M 1 ID 2/2Code identifying the major duty or responsibility of the person or group named

CODE DEFINITION

IC Information ContactSITUATIONAL PER02 93 Name O 1 AN 1/60

Free-form name

28 SITUATIONAL RULE: Required when the contact name is different than thename contained in the Submitter Name (NM1) segment of this loopANDit is the first iteration of the Submitter EDI Contact Information(PER) segment.If not required by this implementation guide, do not send.

IMPLEMENTATION NAME: Submitter Contact Name

REQUIRED PER03 365 Communication Number Qualifier X 1 ID 2/2Code identifying the type of communication number

SYNTAX: P0304

CODE DEFINITION

EM Electronic Mail

FX Facsimile

TE TelephoneREQUIRED PER04 364 Communication Number X 1 AN 1/256

Complete communications number including country or area code whenapplicable

SYNTAX: P0304

SITUATIONAL PER05 365 Communication Number Qualifier X 1 ID 2/2Code identifying the type of communication number

SYNTAX: P0506

29 SITUATIONAL RULE: Required when this information is deemed necessaryby the submitter. If not required by this implementation guide, donot send.

CODE DEFINITION

EM Electronic Mail

005010X223 • 837 • 1000A • PER ASC X12N • INSURANCE SUBCOMMITTEESUBMITTER EDI CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

74 MAY 2006

EX Telephone Extension

FX Facsimile

TE TelephoneSITUATIONAL PER06 364 Communication Number X 1 AN 1/256


SYNTAX: P0506



SYNTAX: P0708


CODE DEFINITION

EM Electronic Mail


FX Facsimile



SYNTAX: P0708


NOT USED PER09 443 Contact Inquiry Reference O 1 AN 1/20

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 1000A • PERTECHNICAL REPORT • TYPE 3 SUBMITTER EDI CONTACT INFORMATION

MAY 2006 75

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 1000B • NM1RECEIVER NAME

SEGMENT DETAIL

30 NM1 - RECEIVER NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Loop 1000 contains submitter and receiver information. If any intermediaryreceivers change or add data in any way, then they add an occurrence tothe loop as a form of identification. The added loop occurrence must be thelast occurrence of the loop.




Loop: 1000B — RECEIVER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

31 TR3 Example: NM1✽ 40✽ 2✽ XYZ RECEIVER✽✽✽✽✽ 46✽ 111222333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038

NM1 ✽ Entity IDCode

✽ Entity TypeQualifier

✽ Name Last/Org Name

✽ NameFirst

✽ NameMiddle

✽ NamePrefix

M 1 ID 2/3 M 1 ID 1/1 X 1 AN 1/60 O 1 AN 1/35 O 1 AN 1/25 O 1 AN 1/10

NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

40 ReceiverREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1

Code qualifying the type of entity


CODE DEFINITION

2 Non-Person Entity

005010X223 • 837 • 1000B • NM1 ASC X12N • INSURANCE SUBCOMMITTEERECEIVER NAME TECHNICAL REPORT • TYPE 3

76 MAY 2006

REQUIRED NM103 1035 Name Last or Organization Name X 1 AN 1/60Individual last name or organizational name

SYNTAX: C1203

IMPLEMENTATION NAME: Receiver Name

NOT USED NM104 1036 Name First O 1 AN 1/35

NOT USED NM105 1037 Name Middle O 1 AN 1/25




SYNTAX: P0809

CODE DEFINITION

46 Electronic Transmitter Identification Number (ETIN)REQUIRED NM109 67 Identification Code X 1 AN 2/80


SYNTAX: P0809

IMPLEMENTATION NAME: Receiver Primary Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 1000B • NM1TECHNICAL REPORT • TYPE 3 RECEIVER NAME

MAY 2006 77

HLHIERARCHICAL LEVEL 005010X223 • 837 • 2000A • HLBILLING PROVIDER HIERARCHICAL LEVEL

SEGMENT DETAIL

399 HL - BILLING PROVIDER HIERARCHICALLEVEL

X12 Segment Name: Hierarchical Level

X12 Purpose: To identify dependencies among and the content of hierarchically relatedgroups of data segments

X12 Comments: 1. The HL segment is used to identify levels of detail information using ahierarchical structure, such as relating line-item data to shipment data, andpackaging data to line-item data.

2. The HL segment defines a top-down/left-right ordered structure.

Loop: 2000A — BILLING PROVIDER HIERARCHICAL LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

32 TR3 Example: HL✽ 1✽✽ 20✽ 1~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736

HL ✽ HierarchID Number ✽ Hierarch

Parent ID ✽ HierarchLevel Code ✽ Hierarch

Child Code ~

M 1 AN 1/12 O 1 AN 1/12 M 1 ID 1/2 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED HL01 628 Hierarchical ID Number M 1 AN 1/12A unique number assigned by the sender to identify a particular data segment ina hierarchical structure

COMMENT: HL01 shall contain a unique alphanumeric number for each occurrenceof the HL segment in the transaction set. For example, HL01 could be used toindicate the number of occurrences of the HL segment, in which case the value ofHL01 would be “1" for the initial HL segment and would be incremented by one ineach subsequent HL segment within the transaction.

34 The first HL01 within each ST-SE envelope must begin with “1”,and be incremented by one each time an HL is used in thetransaction. Only numeric values are allowed in HL01.

NOT USED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12

REQUIRED HL03 735 Hierarchical Level Code M 1 ID 1/2Code defining the characteristic of a level in a hierarchical structure

COMMENT: HL03 indicates the context of the series of segments following thecurrent HL segment up to the next occurrence of an HL segment in thetransaction. For example, HL03 is used to indicate that subsequent segments inthe HL loop form a logical grouping of data referring to shipment, order, or item-level information.

CODE DEFINITION

20 Information Source

005010X223 • 837 • 2000A • HL ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER HIERARCHICAL LEVEL TECHNICAL REPORT • TYPE 3

78 MAY 2006

REQUIRED HL04 736 Hierarchical Child Code O 1 ID 1/1Code indicating if there are hierarchical child data segments subordinate to thelevel being described

COMMENT: HL04 indicates whether or not there are subordinate (or child) HLsegments related to the current HL segment.

CODE DEFINITION

1 Additional Subordinate HL Data Segment in ThisHierarchical Structure.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000A • HLTECHNICAL REPORT • TYPE 3 BILLING PROVIDER HIERARCHICAL LEVEL

MAY 2006 79

PRVPROVIDER INFORMATION 005010X223 • 837 • 2000A • PRVBILLING PROVIDER SPECIALTY INFORMATION

SEGMENT DETAIL

402 PRV - BILLING PROVIDER SPECIALTYINFORMATION

X12 Segment Name: Provider Information

X12 Purpose: To specify the identifying characteristics of a provider

X12 Syntax: 1. P0203If either PRV02 or PRV03 is present, then the other is required.

Loop: 2000A — BILLING PROVIDER HIERARCHICAL LEVEL

Segment Repeat: 1

Usage: SITUATIONAL

1162 Situational Rule: Required when the payer’s adjudication is known to be impacted by theprovider taxonomy code. If not required by this implementation guide, donot send.

1273 TR3 Example: PRV✽ BI✽ PXC✽ 282NR1301X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223

PRV ✽ ProviderCode ✽ Reference

Ident Qual ✽ ReferenceIdent ✽ State or

Prov Code ✽ ProviderSpec. Inf. ✽ Provider

Org Code ~

M 1 ID 1/3 X 1 ID 2/3 X 1 AN 1/50 O 1 ID 2/2 O 1 O 1 ID 3/3

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PRV01 1221 Provider Code M 1 ID 1/3Code identifying the type of provider

CODE DEFINITION

BI BillingREQUIRED PRV02 128 Reference Identification Qualifier X 1 ID 2/3

Code qualifying the Reference Identification

SYNTAX: P0203

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider TaxonomyREQUIRED PRV03 127 Reference Identification X 1 AN 1/50

Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SYNTAX: P0203

IMPLEMENTATION NAME: Provider Taxonomy Code

NOT USED PRV04 156 State or Province Code O 1 ID 2/2

NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O 1

NOT USED PRV06 1223 Provider Organization Code O 1 ID 3/3

005010X223 • 837 • 2000A • PRV ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER SPECIALTY INFORMATION TECHNICAL REPORT • TYPE 3

80 MAY 2006

CURCURRENCY 005010X223 • 837 • 2000A • CURFOREIGN CURRENCY INFORMATION

SEGMENT DETAIL

404 CUR - FOREIGN CURRENCY INFORMATIONX12 Segment Name: Currency

X12 Purpose: To specify the currency (dollars, pounds, francs, etc.) used in a transaction

X12 Syntax: 1. C0807If CUR08 is present, then CUR07 is required.

2. C0907If CUR09 is present, then CUR07 is required.

3. L101112If CUR10 is present, then at least one of CUR11 or CUR12 are required.












X12 Comments: 1. See Figures Appendix for examples detailing the use of the CUR segment.

Loop: 2000A — BILLING PROVIDER HIERARCHICAL LEVEL

Segment Repeat: 1

Usage: SITUATIONAL

405 Situational Rule: Required when the amounts represented in this transaction are currenciesother than the United States dollar. If not required by this implementationguide, do not send.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000A • CURTECHNICAL REPORT • TYPE 3 FOREIGN CURRENCY INFORMATION

MAY 2006 81

406 TR3 Notes: 1. It is REQUIRED that all amounts reported within the transaction are ofthe currency named in this segment. If this segment is not used, thenit is required that all amounts in this transaction be expressed in USdollars.

403 TR3 Example: CUR✽ 85✽ CAD~

DIAGRAM

CUR01 98 CUR02 100 CUR03 280 CUR04 98 CUR05 100 CUR06 669

CUR ✽ Entity IDCode ✽ Currency

Code ✽ ExchangeRate ✽ Entity ID

Code ✽ CurrencyCode ✽ Curr Market

/Exchg CodeM 1 ID 2/3 M 1 ID 3/3 O 1 R 4/10 O 1 ID 2/3 O 1 ID 3/3 O 1 ID 3/3


✽ Date/TimeQualifier ✽ Date ✽ Time ✽ Date/Time

Qualifier ✽ Date ✽ Time

X 1 ID 3/3 O 1 DT 8/8 O 1 TM 4/8 X 1 ID 3/3 X 1 DT 8/8 X 1 TM 4/8


✽ Date/TimeQualifier ✽ Date ✽ Time ✽ Date/Time

Qualifier ✽ Date ✽ Time

X 1 ID 3/3 X 1 DT 8/8 X 1 TM 4/8 X 1 ID 3/3 X 1 DT 8/8 X 1 TM 4/8

CUR19 374 CUR20 373 CUR21 337

✽ Date/TimeQualifier ✽ Date ✽ Time

~

X 1 ID 3/3 X 1 DT 8/8 X 1 TM 4/8

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CUR01 98 Entity Identifier Code M 1 ID 2/3Code identifying an organizational entity, a physical location, property or anindividual

CODE DEFINITION

85 Billing ProviderREQUIRED CUR02 100 Currency Code M 1 ID 3/3

Code (Standard ISO) for country in whose currency the charges are specified

CODE SOURCE 5: Countries, Currencies and Funds

407 The submitter must use the Currency Code, not the Country Code,for this element. For example the Currency Code CAD = Canadiandollars would be valid, while CA = Canada would be invalid.

NOT USED CUR03 280 Exchange Rate O 1 R 4/10

NOT USED CUR04 98 Entity Identifier Code O 1 ID 2/3

NOT USED CUR05 100 Currency Code O 1 ID 3/3

NOT USED CUR06 669 Currency Market/Exchange Code O 1 ID 3/3

NOT USED CUR07 374 Date/Time Qualifier X 1 ID 3/3

NOT USED CUR08 373 Date O 1 DT 8/8

005010X223 • 837 • 2000A • CUR ASC X12N • INSURANCE SUBCOMMITTEEFOREIGN CURRENCY INFORMATION TECHNICAL REPORT • TYPE 3

82 MAY 2006

NOT USED CUR09 337 Time O 1 TM 4/8


NOT USED CUR11 373 Date X 1 DT 8/8

NOT USED CUR12 337 Time X 1 TM 4/8










ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000A • CURTECHNICAL REPORT • TYPE 3 FOREIGN CURRENCY INFORMATION

MAY 2006 83

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010AA • NM1BILLING PROVIDER NAME

SEGMENT DETAIL

408 NM1 - BILLING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Loop 2010 contains information about entities that apply to all claims in loop2300. For example, these entities may include billing provider, pay-toprovider, insurer, primary administrator, contract holder, or claimant.




Loop: 2010AA — BILLING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

410 TR3 Notes: 1. Beginning on the NPI compliance date: When the Billing Provider isan organization health care provider, the organization health careprovider’s NPI or its subpart’s NPI is reported in NM109. When ahealth care provider organization has determined that it needs toenumerate its subparts, it will report the NPI of a subpart as the BillingProvider. The subpart reported as the Billing Provider MUST alwaysrepresent the most detailed level of enumeration as determined by theorganization health care provider and MUST be the same identifiersent to any trading partner. For additional explanation, see section1.10.3 Organization Health Care Provider Subpart Presentation.

38 2. Prior to the NPI compliance date, proprietary identifiers necessary forthe receiver to identify the Billing Provider entity are to be reported inthe REF segment of Loop ID-2010BB.

39 3. The Taxpayer Identifying Number (TIN) of the Billing Provider to beused for 1099 purposes must be reported in the REF segment of thisloop.

40 4. When the individual or the organization is not a health care providerand, thus, not eligible to receive an NPI (For example, personal careservices, carpenters, etc), the Billing Provider should be the legalentity. However, willing trading partners may agree upon varyingdefinitions. Proprietary identifiers necessary for the receiver toidentify the entity are to be reported in the Loop ID-2010BB REF,Billing Provider Secondary Identification segment. The TIN to be usedfor 1099 purposes must be reported in the REF (Tax IdentificationNumber) segment of this loop.

35 TR3 Example: NM1✽ 85✽ 2✽ ABC HOSPITAL✽✽✽✽✽ XX✽ 1234567890~

005010X223 • 837 • 2010AA • NM1 ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER NAME TECHNICAL REPORT • TYPE 3

84 MAY 2006

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

85 Billing ProviderREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Billing Provider Organizational Name





ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AA • NM1TECHNICAL REPORT • TYPE 3 BILLING PROVIDER NAME

MAY 2006 85

SITUATIONAL NM108 66 Identification Code Qualifier X 1 ID 1/2Code designating the system/method of code structure used for IdentificationCode (67)

SYNTAX: P0809

44 SITUATIONAL RULE: Required for providers in the United States or itsterritories on or after the mandated HIPAA National ProviderIdentifier (NPI) implementation date when the provider is eligible toreceive an NPI.ORRequired for providers not in the United States or its territories onor after the mandated HIPAA National Provider Identifier (NPI)implementation date when the provider has received an NPI.ORRequired for providers prior to the mandated NPI implementationdate when the provider has received an NPI and the submitter hasthe capability to send it.If not required by this implementation guide, do not send.

CODE DEFINITION

XX Centers for Medicare and Medicaid ServicesNational Provider Identifier

CODE SOURCE 537: Centers for Medicare and Medicaid ServicesNational Provider Identifier

SITUATIONAL NM109 67 Identification Code X 1 AN 2/80Code identifying a party or other code

SYNTAX: P0809


IMPLEMENTATION NAME: Billing Provider Identifier




005010X223 • 837 • 2010AA • NM1 ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER NAME TECHNICAL REPORT • TYPE 3

86 MAY 2006

N3PARTY LOCATION 005010X223 • 837 • 2010AA • N3BILLING PROVIDER ADDRESS

SEGMENT DETAIL

412 N3 - BILLING PROVIDER ADDRESSX12 Segment Name: Party Location

X12 Purpose: To specify the location of the named party

Loop: 2010AA — BILLING PROVIDER NAME

Segment Repeat: 1

Usage: REQUIRED

1074 TR3 Notes: 1. The Billing Provider Address must be a street address. Post OfficeBox or Lock Box addresses are to be sent in the Pay-To Address Loop(Loop ID-2010AB), if necessary.

84 TR3 Example: N3✽ 123 MAIN STREET~

DIAGRAM

N301 166 N302 166

N3 ✽ AddressInformation ✽ Address

Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED N301 166 Address Information M 1 AN 1/55Address information

IMPLEMENTATION NAME: Billing Provider Address Line

SITUATIONAL N302 166 Address Information O 1 AN 1/55Address information

87 SITUATIONAL RULE: Required when there is a second address line. If notrequired by this implementation guide, do not send.

IMPLEMENTATION NAME: Billing Provider Address Line

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AA • N3TECHNICAL REPORT • TYPE 3 BILLING PROVIDER ADDRESS

MAY 2006 87

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010AA • N4BILLING PROVIDER CITY, STATE, ZIP CODE

SEGMENT DETAIL

413 N4 - BILLING PROVIDER CITY, STATE, ZIPCODE

X12 Segment Name: Geographic Location

X12 Purpose: To specify the geographic place of the named party

X12 Syntax: 1. E0207Only one of N402 or N407 may be present.

2. C0605If N406 is present, then N405 is required.



Segment Repeat: 1

Usage: REQUIRED

1548 TR3 Example: N4✽ KANSAS CITY✽ MO✽ 64108~

DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310

N4 ✽ CityName ✽ State or

Prov Code ✽ PostalCode ✽ Country

Code ✽ LocationQualifier ✽ Location

IdentifierO 1 AN 2/30 X 1 ID 2/2 O 1 ID 3/15 X 1 ID 2/3 X 1 ID 1/2 O 1 AN 1/30

N407 1715

✽ Country SubCode ~

X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED N401 19 City Name O 1 AN 2/30Free-form text for city name

COMMENT: A combination of either N401 through N404, or N405 and N406 may beadequate to specify a location.

IMPLEMENTATION NAME: Billing Provider City Name

005010X223 • 837 • 2010AA • N4 ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

88 MAY 2006

SITUATIONAL N402 156 State or Province Code X 1 ID 2/2Code (Standard State/Province) as defined by appropriate government agency

SYNTAX: E0207

COMMENT: N402 is required only if city name (N401) is in the U.S. or Canada.

1549 SITUATIONAL RULE: Required when the address is in the United States ofAmerica, including its territories, or Canada. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Billing Provider State or Province Code

CODE SOURCE 22: States and Provinces

SITUATIONAL N403 116 Postal Code O 1 ID 3/15Code defining international postal zone code excluding punctuation and blanks(zip code for United States)

1550 SITUATIONAL RULE: Required when the address is in the United States ofAmerica, including its territories, or Canada, or when a postal codeexists for the country in N404. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Billing Provider Postal Zone or ZIP Code

CODE SOURCE 51: ZIP CodeCODE SOURCE 932: Universal Postal Codes

1552 When reporting the ZIP code for U.S. addresses, the full nine digitZIP code must be provided.

SITUATIONAL N404 26 Country Code X 1 ID 2/3Code identifying the country

SYNTAX: C0704

1551 SITUATIONAL RULE: Required when the address is outside the UnitedStates of America. If not required by this implementation guide, donot send.


1552 Use the alpha-2 country codes from Part 1 of ISO 3166.

NOT USED N405 309 Location Qualifier X 1 ID 1/2

NOT USED N406 310 Location Identifier O 1 AN 1/30

SITUATIONAL N407 1715 Country Subdivision Code X 1 ID 1/3Code identifying the country subdivision

SYNTAX: E0207, C0704

1553 SITUATIONAL RULE: Required when the address is not in the UnitedStates of America, including its territories, or Canada, and thecountry in N404 has administrative subdivisions such as but notlimited to states, provinces, cantons, etc. If not required by thisimplementation guide, do not send.


1554 Use the country subdivision codes from Part 2 of ISO 3166.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AA • N4TECHNICAL REPORT • TYPE 3 BILLING PROVIDER CITY, STATE, ZIP CODE

MAY 2006 89

REFREFERENCE INFORMATION 005010X223 • 837 • 2010AA • REFBILLING PROVIDER TAX IDENTIFICATION

SEGMENT DETAIL

1487 REF - BILLING PROVIDER TAXIDENTIFICATION

X12 Segment Name: Reference Information

X12 Purpose: To specify identifying information

X12 Syntax: 1. R0203At least one of REF02 or REF03 is required.


Segment Repeat: 1

Usage: REQUIRED

415 TR3 Notes: 1. This is the tax identification number (TIN) of the entity to be paid forthe submitted services.

416 TR3 Example: REF✽ EI✽ 123456789~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040

REF ✽ ReferenceIdent Qual ✽ Reference

Ident ✽ Description ✽ ReferenceIdentifier ~

M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED REF01 128 Reference Identification Qualifier M 1 ID 2/3Code qualifying the Reference Identification

CODE DEFINITION

EI Employer’s Identification Number

112 The Employer’s Identification Number must be astring of exactly nine numbers with no separators.

For example, “001122333” would be valid, whilesending “001-12-2333” or “00-1122333” would beinvalid.

REQUIRED REF02 127 Reference Identification X 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SYNTAX: R0203

IMPLEMENTATION NAME: Billing Provider Tax Identification Number

NOT USED REF03 352 Description X 1 AN 1/80

NOT USED REF04 C040 REFERENCE IDENTIFIER O 1

005010X223 • 837 • 2010AA • REF ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER TAX IDENTIFICATION TECHNICAL REPORT • TYPE 3

90 MAY 2006

PERADMINISTRATIVE COMMUNICATIONS CONTACT 005010X223 • 837 • 2010AA • PERBILLING PROVIDER CONTACT INFORMATION

SEGMENT DETAIL

419 PER - BILLING PROVIDER CONTACTINFORMATION

X12 Segment Name: Administrative Communications Contact

X12 Purpose: To identify a person or office to whom administrative communications should bedirected

X12 Syntax: 1. P0304If either PER03 or PER04 is present, then the other is required.




Segment Repeat: 2

Usage: SITUATIONAL

420 Situational Rule: Required when this information is different than that contained in theLoop ID-1000A - Submitter PER segment. If not required by thisimplementation guide, do not send.

24 TR3 Notes: 1. When the communication number represents a telephone number inthe United States and other countries using the North AmericanDialing Plan (for voice, data, fax, etc.), the communication numbermust always include the area code and phone number using theformat AAABBBCCCC where AAA is the area code, BBB is thetelephone number prefix, and CCCC is the telephone number.Therefore, the following telephone number (555) 555-1234 would berepresented as 5555551234. Do not submit long distance accessnumbers, such as “1”, in the telephone number. Telephoneextensions, when applicable, must be submitted in the next elementimmediately following the telephone number. When submittingtelephone extensions, only submit the numeric extension. Do notinclude data that indicates an extension, such as “ext” or “x-”.

27 2. There are 2 repetitions of the PER segment to allow for six possiblecombinations of communication numbers including extensions.

450 TR3 Example: PER✽ IC✽ JOHN SMITH✽ TE✽ 5555551234✽ EX✽ 123~

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AA • PERTECHNICAL REPORT • TYPE 3 BILLING PROVIDER CONTACT INFORMATION

MAY 2006 91

DIAGRAM

PER01 366 PER02 93 PER03 365 PER04 364 PER05 365 PER06 364

PER ✽ ContactFunct Code ✽ Name ✽ Comm

Number Qual ✽ CommNumber ✽ Comm

Number Qual ✽ CommNumber

M 1 ID 2/2 O 1 AN 1/60 X 1 ID 2/2 X 1 AN 1/256 X 1 ID 2/2 X 1 AN 1/256

PER07 365 PER08 364 PER09 443

✽ CommNumber Qual ✽ Comm

Number ✽ Contact InqReference ~

X 1 ID 2/2 X 1 AN 1/256 O 1 AN 1/20

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PER01 366 Contact Function Code M 1 ID 2/2Code identifying the major duty or responsibility of the person or group named

CODE DEFINITION

IC Information ContactSITUATIONAL PER02 93 Name O 1 AN 1/60

Free-form name

421 SITUATIONAL RULE: Required in the first iteration of the Billing ProviderContact Information segment. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Billing Provider Contact Name

REQUIRED PER03 365 Communication Number Qualifier X 1 ID 2/2Code identifying the type of communication number

SYNTAX: P0304

CODE DEFINITION

EM Electronic Mail

FX Facsimile

TE TelephoneREQUIRED PER04 364 Communication Number X 1 AN 1/256


SYNTAX: P0304


SYNTAX: P0506


CODE DEFINITION

EM Electronic Mail


FX Facsimile

TE Telephone

005010X223 • 837 • 2010AA • PER ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER CONTACT INFORMATION TECHNICAL REPORT • TYPE 3

92 MAY 2006

SITUATIONAL PER06 364 Communication Number X 1 AN 1/256Complete communications number including country or area code whenapplicable

SYNTAX: P0506



SYNTAX: P0708


CODE DEFINITION

EM Electronic Mail


FX Facsimile



SYNTAX: P0708


NOT USED PER09 443 Contact Inquiry Reference O 1 AN 1/20

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AA • PERTECHNICAL REPORT • TYPE 3 BILLING PROVIDER CONTACT INFORMATION

MAY 2006 93

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010AB • NM1PAY-TO ADDRESS NAME

SEGMENT DETAIL

425 NM1 - PAY-TO ADDRESS NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2010AB — PAY-TO ADDRESS NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

423 Situational Rule: Required when the address for payment is different than that of the BillingProvider. If not required by this implementation guide, do not send.

424 TR3 Notes: 1. The purpose of Loop ID-2010AB has changed from previous versions.Loop ID-2010AB only contains address information when differentfrom the Billing Provider Address. There are no applicable identifiersfor Pay-To Address information.

422 TR3 Example: NM1✽ 87✽ 2~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038




✽ NameFirst

✽ NameMiddle

✽ NamePrefix


NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035

✽ NameSuffix

✽ ID CodeQualifier

✽ IDCode

✽ EntityRelat Code

✽ Entity IDCode

✽ Name Last/Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

87 Pay-to Provider

005010X223 • 837 • 2010AB • NM1 ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO ADDRESS NAME TECHNICAL REPORT • TYPE 3

94 MAY 2006



CODE DEFINITION

2 Non-Person EntityNOT USED NM103 1035 Name Last or Organization Name X 1 AN 1/60





NOT USED NM108 66 Identification Code Qualifier X 1 ID 1/2

NOT USED NM109 67 Identification Code X 1 AN 2/80




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AB • NM1TECHNICAL REPORT • TYPE 3 PAY-TO ADDRESS NAME

MAY 2006 95

N3PARTY LOCATION 005010X223 • 837 • 2010AB • N3PAY-TO ADDRESS - ADDRESS

SEGMENT DETAIL

426 N3 - PAY-TO ADDRESS - ADDRESSX12 Segment Name: Party Location


Loop: 2010AB — PAY-TO ADDRESS NAME

Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Pay-To Address Line



IMPLEMENTATION NAME: Pay-To Address Line

005010X223 • 837 • 2010AB • N3 ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO ADDRESS - ADDRESS TECHNICAL REPORT • TYPE 3

96 MAY 2006

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010AB • N4PAY-TO ADDRESS CITY, STATE, ZIP CODE

SEGMENT DETAIL

427 N4 - PAY-TO ADDRESS CITY, STATE, ZIPCODE






Loop: 2010AB — PAY-TO ADDRESS NAME

Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Pay-to Address City Name

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AB • N4TECHNICAL REPORT • TYPE 3 PAY-TO ADDRESS CITY, STATE, ZIP CODE

MAY 2006 97


SYNTAX: E0207



IMPLEMENTATION NAME: Pay-to Address State Code




IMPLEMENTATION NAME: Pay-to Address Postal Zone or ZIP Code



SYNTAX: C0704











005010X223 • 837 • 2010AB • N4 ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO ADDRESS CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

98 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010AC • NM1PAY-TO PLAN NAME

SEGMENT DETAIL

428 NM1 - PAY-TO PLAN NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2010AC — PAY-TO PLAN NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

430 Situational Rule: Required when willing trading partners agree to use this implementationfor their subrogation payment requests.

1453 TR3 Notes: 1. This loop may only be used when BHT06 = 31.

429 TR3 Example: NM1✽ PE✽ 2✽ ANY STATE MEDICAID✽✽✽✽✽ PI✽ 12345~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

PE Payee

431 PE is used to indicate the subrogated payee.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AC • NM1TECHNICAL REPORT • TYPE 3 PAY-TO PLAN NAME

MAY 2006 99

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CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Pay-To Plan Organizational Name






SYNTAX: P0809

107 On or after the mandated implementation date for the HIPAANational Plan Identifier (National Plan ID), XV must be sent.

Prior to the mandated implementation date and prior to any phase-in period identified by Federal regulation, PI must be sent.

If a phase-in period is designated, PI must be sent unless:1. Both the sender and receiver agree to use the National Plan ID, 2. The receiver has a National Plan ID, and3. The sender has the capability to send the National Plan ID.

If all of the above conditions are true, XV must be sent. In this casethe Payer Identification Number that would have been sent usingqualifier PI can be sent in the corresponding REF segment usingqualifier 2U.

CODE DEFINITION

PI Payor Identification

XV Centers for Medicare and Medicaid Services PlanID

CODE SOURCE 540: Centers for Medicare and Medicaid ServicesPlanID

REQUIRED NM109 67 Identification Code X 1 AN 2/80Code identifying a party or other code

SYNTAX: P0809

IMPLEMENTATION NAME: Pay-To Plan Primary Identifier




005010X223 • 837 • 2010AC • NM1 ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO PLAN NAME TECHNICAL REPORT • TYPE 3

100 MAY 2006

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N3PARTY LOCATION 005010X223 • 837 • 2010AC • N3PAY-TO PLAN ADDRESS

SEGMENT DETAIL

432 N3 - PAY-TO PLAN ADDRESSX12 Segment Name: Party Location


Loop: 2010AC — PAY-TO PLAN NAME

Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Pay-To Plan Address Line



IMPLEMENTATION NAME: Pay-To Plan Address Line

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AC • N3TECHNICAL REPORT • TYPE 3 PAY-TO PLAN ADDRESS

MAY 2006 101

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N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010AC • N4PAY-TO PLAN CITY, STATE, ZIP CODE

SEGMENT DETAIL

433 N4 - PAY-TO PLAN CITY, STATE, ZIP CODEX12 Segment Name: Geographic Location






Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Pay-To Plan City Name


SYNTAX: E0207



IMPLEMENTATION NAME: Pay-To Plan State or Province Code


005010X223 • 837 • 2010AC • N4 ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO PLAN CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

102 MAY 2006

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IMPLEMENTATION NAME: Pay-To Plan Postal Zone or ZIP Code



SYNTAX: C0704











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AC • N4TECHNICAL REPORT • TYPE 3 PAY-TO PLAN CITY, STATE, ZIP CODE

MAY 2006 103

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REFREFERENCE INFORMATION 005010X223 • 837 • 2010AC • REFPAY-TO PLAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

434 REF - PAY-TO PLAN SECONDARYIDENTIFICATION





Segment Repeat: 1

Usage: SITUATIONAL

110 Situational Rule: Required prior to the mandated implementation date for the HIPAANational Plan Identifier when an additional identification number to thatprovided in the NM109 of this loop is necessary for the claim processor toidentify the entity. If not required by this implementation guide, do notsend.

435 TR3 Example: REF✽ 2U✽ 98765~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

2U Payer Identification Number

1442 This code is only allowed when the National PlanIdentifier is reported in NM109 of this loop.

FY Claim Office Number

NF National Association of Insurance Commissioners(NAIC) Code

CODE SOURCE 245: National Association of InsuranceCommissioners (NAIC) Code


SYNTAX: R0203

IMPLEMENTATION NAME: Pay-to Plan Secondary Identifier


005010X223 • 837 • 2010AC • REF ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO PLAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

104 MAY 2006

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ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010AC • REFTECHNICAL REPORT • TYPE 3 PAY-TO PLAN SECONDARY IDENTIFICATION

MAY 2006 105

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REFREFERENCE INFORMATION 005010X223 • 837 • 2010AC • REFPAY-TO PLAN TAX IDENTIFICATION NUMBER

SEGMENT DETAIL

1556 REF - PAY-TO PLAN TAX IDENTIFICATIONNUMBER





Segment Repeat: 1

Usage: REQUIRED

416 TR3 Example: REF✽ EI✽ 123456789~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION





SYNTAX: R0203

IMPLEMENTATION NAME: Pay-To Plan Tax Identification Number



005010X223 • 837 • 2010AC • REF ASC X12N • INSURANCE SUBCOMMITTEEPAY-TO PLAN TAX IDENTIFICATION NUMBER TECHNICAL REPORT • TYPE 3

106 MAY 2006

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HLHIERARCHICAL LEVEL 005010X223 • 837 • 2000B • HLSUBSCRIBER HIERARCHICAL LEVEL

SEGMENT DETAIL

54 HL - SUBSCRIBER HIERARCHICAL LEVELX12 Segment Name: Hierarchical Level




Loop: 2000B — SUBSCRIBER HIERARCHICAL LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: REQUIRED

56 TR3 Notes: 1. If a patient can be uniquely identified to the destination payer in LoopID-2010BB by a unique Member Identification Number, then the patientis the subscriber or is considered to be the subscriber and isidentified at this level, and the patient HL in Loop ID-2000C is not used.

57 2. If the patient is not the subscriber and cannot be identified to thedestination payer by a unique Member Identification Number or it isnot known to the sender if the Member Identification number isunique, both this HL and the patient HL in Loop ID- 2000C are required.

55 TR3 Example: HL✽ 2✽ 1✽ 22✽ 1~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736



Child Code ~

M 1 AN 1/12 O 1 AN 1/12 M 1 ID 1/2 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.




34 The first HL01 within each ST-SE envelope must begin with “1”,and be incremented by one each time an HL is used in thetransaction. Only numeric values are allowed in HL01.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000B • HLTECHNICAL REPORT • TYPE 3 SUBSCRIBER HIERARCHICAL LEVEL

MAY 2006 107

REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12Identification number of the next higher hierarchical data segment that the datasegment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to whichthe current HL segment is subordinate.



CODE DEFINITION

22 SubscriberREQUIRED HL04 736 Hierarchical Child Code O 1 ID 1/1

Code indicating if there are hierarchical child data segments subordinate to thelevel being described


58 The claim (Loop ID-2300) can be used when HL04 has nosubordinate levels (HL04 = 0) or when HL04 has subordinate levelsindicated (HL04 = 1).

59 In the first case (HL04 = 0), the subscriber is the patient and thereare no dependent claims.

60 The second case (HL04 = 1) happens when claims for one or moredependents of the subscriber are being sent under the same billingprovider HL (for example, a spouse and son are both treated by thesame provider). In that case, the subscriber HL04 = 1 because thereis at least one dependent to this subscriber. The dependent HL(spouse) would then be sent followed by the Loop ID-2300 for thespouse. The next HL would be the dependent HL for the sonfollowed by the Loop ID-2300 for the son.

61 In order to send claims for the subscriber and one or moredependents, the Subscriber HL, with Relationship Code SBR02=18(Self), would be followed by the Subscriber’s Loop ID-2300 for theSubscriber’s claims. Then the Subscriber HL would be repeated,followed by one or more Patient HL loops for the dependents, withthe proper Relationship Code in PAT01, each followed by theirrespective Loop ID-2300 for each dependent’s claims.

CODE DEFINITION

0 No Subordinate HL Segment in This HierarchicalStructure.

1 Additional Subordinate HL Data Segment in ThisHierarchical Structure.

005010X223 • 837 • 2000B • HL ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER HIERARCHICAL LEVEL TECHNICAL REPORT • TYPE 3

108 MAY 2006

SBRSUBSCRIBER INFORMATION 005010X223 • 837 • 2000B • SBRSUBSCRIBER INFORMATION

SEGMENT DETAIL

62 SBR - SUBSCRIBER INFORMATIONX12 Segment Name: Subscriber Information

X12 Purpose: To record information specific to the primary insured and the insurance carrierfor that insured

Loop: 2000B — SUBSCRIBER HIERARCHICAL LEVEL

Segment Repeat: 1

Usage: REQUIRED

63 TR3 Example: SBR✽ P✽✽ GRP01020102✽✽✽✽✽✽ CI~

DIAGRAM

SBR01 1138 SBR02 1069 SBR03 127 SBR04 93 SBR05 1336 SBR06 1143

SBR ✽ Payer RespSeq No Code ✽ Individual

Relat Code ✽ ReferenceIdent ✽ Name ✽ Insurance

Type Code ✽ BenefitsCoord Code

M 1 ID 1/1 O 1 ID 2/2 O 1 AN 1/50 O 1 AN 1/60 O 1 ID 1/3 O 1 ID 1/1

SBR07 1073 SBR08 584 SBR09 1032

✽ Yes/No CondResp Code ✽ Employment

Status Code ✽ Claim FileInd Code ~

O 1 ID 1/1 O 1 ID 2/2 O 1 ID 1/2

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED SBR01 1138 Payer Responsibility Sequence Number Code M 1 ID 1/1Code identifying the insurance carrier’s level of responsibility for a payment of aclaim

64 Within a given claim, the various values for the PayerResponsibility Sequence Number Code (other than value “U”) mayoccur no more than once.

CODE DEFINITION

A Payer Responsibility Four

B Payer Responsibility Five

C Payer Responsibility Six

D Payer Responsibility Seven

E Payer Responsibility Eight

F Payer Responsibility Nine

G Payer Responsibility Ten

H Payer Responsibility Eleven

P Primary

S Secondary

T Tertiary

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000B • SBRTECHNICAL REPORT • TYPE 3 SUBSCRIBER INFORMATION

MAY 2006 109

U Unknown

65 This code may only be used in payer to payer COBclaims when the original payer determined thepresence of this coverage from eligibility filesreceived from this payer or when the original claimdid not provide the responsibility sequence for thispayer.

SITUATIONAL SBR02 1069 Individual Relationship Code O 1 ID 2/2Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

66 SITUATIONAL RULE: Required when the patient is the subscriber or isconsidered to be the subscriber. If not required by thisimplementation guide, do not send.

CODE DEFINITION

18 SelfSITUATIONAL SBR03 127 Reference Identification O 1 AN 1/50


SEMANTIC: SBR03 is policy or group number.

68 SITUATIONAL RULE: Required when the subscriber’s identification cardfor the destination payer (Loop ID-2010BB) shows a group number.If not required by this implementation guide, do not send.

IMPLEMENTATION NAME: Subscriber Group or Policy Number

67 This is not the number uniquely identifying the subscriber. Theunique subscriber number is submitted in Loop ID-2010BA-NM109.

SITUATIONAL SBR04 93 Name O 1 AN 1/60Free-form name

SEMANTIC: SBR04 is plan name.

313 SITUATIONAL RULE: Required when SBR03 is not used and the groupname is available. If not required by this implementation guide, donot send.

IMPLEMENTATION NAME: Subscriber Group Name

NOT USED SBR05 1336 Insurance Type Code O 1 ID 1/3

NOT USED SBR06 1143 Coordination of Benefits Code O 1 ID 1/1

NOT USED SBR07 1073 Yes/No Condition or Response Code O 1 ID 1/1

NOT USED SBR08 584 Employment Status Code O 1 ID 2/2

SITUATIONAL SBR09 1032 Claim Filing Indicator Code O 1 ID 1/2Code identifying type of claim

314 SITUATIONAL RULE: Required prior to mandated use of the HIPAANational Plan ID. If not required by this implementation guide, donot send.

CODE DEFINITION

11 Other Non-Federal Programs

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

005010X223 • 837 • 2000B • SBR ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER INFORMATION TECHNICAL REPORT • TYPE 3

110 MAY 2006

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) MedicareRisk

17 Dental Maintenance Organization

AM Automobile Medical

BL Blue Cross/Blue Shield

CH Champus

CI Commercial Insurance Co.

DS Disability

FI Federal Employees Program

HM Health Maintenance Organization

LM Liability Medical

MA Medicare Part A

MB Medicare Part B

MC Medicaid

OF Other Federal Program

1484 Use code OF when submitting Medicare Part Dclaims.

TV Title V

VA Veterans Affairs Plan

WC Workers’ Compensation Health Claim

ZZ Mutually Defined

71 Use Code ZZ when Type of Insurance is not known.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000B • SBRTECHNICAL REPORT • TYPE 3 SUBSCRIBER INFORMATION

MAY 2006 111

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010BA • NM1SUBSCRIBER NAME

SEGMENT DETAIL

77 NM1 - SUBSCRIBER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2010BA — SUBSCRIBER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

79 TR3 Notes: 1. In worker’s compensation or other property and casualty claims, the“subscriber” may be a non-person entity (for example, the employer).However, this varies by state.

78 TR3 Example: NM1✽ IL✽ 1✽ DOE✽ JOHN✽ T✽✽ JR✽ MI✽ 123456~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

IL Insured or Subscriber

005010X223 • 837 • 2010BA • NM1 ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

112 MAY 2006



CODE DEFINITION

1 Person



SYNTAX: C1203

IMPLEMENTATION NAME: Subscriber Last Name



IMPLEMENTATION NAME: Subscriber First Name



IMPLEMENTATION NAME: Subscriber Middle Name or Initial


SITUATIONAL NM107 1039 Name Suffix O 1 AN 1/10Suffix to individual name

80 SITUATIONAL RULE: Required when NM102 = 1 (person) and the namesuffix of the person is needed to identify the individual. If notrequired by this implementation guide, do not send.

IMPLEMENTATION NAME: Subscriber Name Suffix

81 Examples: I, II, III, IV, Jr, SrThis data element is used only to indicate generation or patronymic.


SYNTAX: P0809

CODE DEFINITION

II Standard Unique Health Identifier for each Individualin the United States

1540 Required if the HIPAA Individual Patient Identifier ismandated use. If not required, use value ‘MI’instead.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BA • NM1TECHNICAL REPORT • TYPE 3 SUBSCRIBER NAME

MAY 2006 113

MI Member Identification Number

82 The code MI is intended to be the subscriber’sidentification number as assigned by the payer. (Forexample, Insured’s ID, Subscriber’s ID, HealthInsurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted tothe Indian Health Service/Contract Health Services(IHS/CHS) Fiscal Intermediary for the purpose ofreporting the Tribe Residency Code (Tribe CountyState). In the event that a Social Security Number(SSN) is also available on an IHS/CHS claim, put theSSN in REF02.

When sending the Social Security Number as theMember ID, it must be a string of exactly ninenumbers with no separators. For example, sending“111002222” would be valid, while sending “111-00-2222” would be invalid.


SYNTAX: P0809

IMPLEMENTATION NAME: Subscriber Primary Identifier




005010X223 • 837 • 2010BA • NM1 ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

114 MAY 2006

N3PARTY LOCATION 005010X223 • 837 • 2010BA • N3SUBSCRIBER ADDRESS

SEGMENT DETAIL

85 N3 - SUBSCRIBER ADDRESSX12 Segment Name: Party Location


Loop: 2010BA — SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

86 Situational Rule: Required when the patient is the subscriber or considered to be thesubscriber. If not required by this implementation guide, do not send.


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Subscriber Address Line



IMPLEMENTATION NAME: Subscriber Address Line

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BA • N3TECHNICAL REPORT • TYPE 3 SUBSCRIBER ADDRESS

MAY 2006 115

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010BA • N4SUBSCRIBER CITY, STATE, ZIP CODE

SEGMENT DETAIL

89 N4 - SUBSCRIBER CITY, STATE, ZIP CODEX12 Segment Name: Geographic Location






Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Subscriber City Name


SYNTAX: E0207



IMPLEMENTATION NAME: Subscriber State Code


005010X223 • 837 • 2010BA • N4 ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

116 MAY 2006

tdrinkard

Text Box

Change the usage to Situational with the following Situational Rule: "Required when the patient is the subscriber or considered to be the subscriber. If not required by this implementation guide, do not send."

tdrinkard

Highlight



IMPLEMENTATION NAME: Subscriber Postal Zone or ZIP Code



SYNTAX: C0704











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BA • N4TECHNICAL REPORT • TYPE 3 SUBSCRIBER CITY, STATE, ZIP CODE

MAY 2006 117

DMGDEMOGRAPHIC INFORMATION 005010X223 • 837 • 2010BA • DMGSUBSCRIBER DEMOGRAPHIC INFORMATION

SEGMENT DETAIL

93 DMG - SUBSCRIBER DEMOGRAPHICINFORMATION

X12 Segment Name: Demographic Information

X12 Purpose: To supply demographic information

X12 Syntax: 1. P0102If either DMG01 or DMG02 is present, then the other is required.

2. P1011If either DMG10 or DMG11 is present, then the other is required.

3. C1105If DMG11 is present, then DMG05 is required.


Segment Repeat: 1

Usage: SITUATIONAL

86 Situational Rule: Required when the patient is the subscriber or considered to be thesubscriber. If not required by this implementation guide, do not send.

94 TR3 Example: DMG✽ D8✽ 19690815✽ M~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066

DMG ✽ Date TimeFormat Qual ✽ Date Time

Period ✽ GenderCode ✽ Marital

Status Code ✽ Comp Raceor Ethn Inf ✽ Citizenship

Status CodeX 1 ID 2/3 X 1 AN 1/35 O 1 ID 1/1 O 1 ID 1/1 X 10 O 1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

✽ CountryCode ✽ Basis of

Verif Code ✽ Quantity ✽ Code ListQual Code ✽ Industry

Code ~

O 1 ID 2/3 O 1 ID 1/2 O 1 R 1/15 X 1 ID 1/3 X 1 AN 1/30

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED DMG01 1250 Date Time Period Format Qualifier X 1 ID 2/3Code indicating the date format, time format, or date and time format

SYNTAX: P0102

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDDREQUIRED DMG02 1251 Date Time Period X 1 AN 1/35

Expression of a date, a time, or range of dates, times or dates and times

SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

IMPLEMENTATION NAME: Subscriber Birth Date

005010X223 • 837 • 2010BA • DMG ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

118 MAY 2006

REQUIRED DMG03 1068 Gender Code O 1 ID 1/1Code indicating the sex of the individual

IMPLEMENTATION NAME: Subscriber Gender Code

CODE DEFINITION

F Female

M Male

U UnknownNOT USED DMG04 1067 Marital Status Code O 1 ID 1/1

NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITYINFORMATION

X10

NOT USED DMG06 1066 Citizenship Status Code O 1 ID 1/2

NOT USED DMG07 26 Country Code O 1 ID 2/3

NOT USED DMG08 659 Basis of Verification Code O 1 ID 1/2

NOT USED DMG09 380 Quantity O 1 R 1/15

NOT USED DMG10 1270 Code List Qualifier Code X 1 ID 1/3

NOT USED DMG11 1271 Industry Code X 1 AN 1/30

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BA • DMGTECHNICAL REPORT • TYPE 3 SUBSCRIBER DEMOGRAPHIC INFORMATION

MAY 2006 119

REFREFERENCE INFORMATION 005010X223 • 837 • 2010BA • REFSUBSCRIBER SECONDARY IDENTIFICATION

SEGMENT DETAIL

100 REF - SUBSCRIBER SECONDARYIDENTIFICATION





Segment Repeat: 1

Usage: SITUATIONAL

326 Situational Rule: Required when an additional identification number to that provided inNM109 of this loop is necessary for the claim processor to identify theentity. If not required by this implementation guide, do not send.

101 TR3 Example: REF✽ SY✽ 123456789~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

SY Social Security Number

327 The Social Security Number must be a string ofexactly nine numbers with no separators. Forexample, sending “111002222” would be valid, whilesending “111-00-2222” would be invalid.


SYNTAX: R0203

IMPLEMENTATION NAME: Subscriber Supplemental Identifier



005010X223 • 837 • 2010BA • REF ASC X12N • INSURANCE SUBCOMMITTEESUBSCRIBER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

120 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2010BA • REFPROPERTY AND CASUALTY CLAIM NUMBER

SEGMENT DETAIL

444 REF - PROPERTY AND CASUALTY CLAIMNUMBER





Segment Repeat: 1

Usage: SITUATIONAL

446 Situational Rule: Required when the services included in this claim are to be considered aspart of a property and casualty claim. If not required by thisimplementation guide, do not send.

447 TR3 Notes: 1. This is a property and casualty payer-assigned claim number.Providers receive this number from the property and casualty payerduring eligibility determinations or some other communication withthat payer. See Section 1.4.2, Property and Casualty, for additionalinformation about property and casualty claims.

448 2. This segment is not a HIPAA requirement as of this writing.

445 TR3 Example: REF✽ Y4✽ 4445555~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

Y4 Agency Claim NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Property Casualty Claim Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BA • REFTECHNICAL REPORT • TYPE 3 PROPERTY AND CASUALTY CLAIM NUMBER

MAY 2006 121

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010BB • NM1PAYER NAME

SEGMENT DETAIL

105 NM1 - PAYER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2010BB — PAYER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

106 TR3 Notes: 1. This is the destination payer.

1485 2. For the purposes of this implementation the term payer issynonymous with several other terms, such as, repricer and thirdparty administrator.

104 TR3 Example: NM1✽ PR✽ 2✽ ABC INSURANCE CO✽✽✽✽✽ PI✽ 11122333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

PR Payer

005010X223 • 837 • 2010BB • NM1 ASC X12N • INSURANCE SUBCOMMITTEEPAYER NAME TECHNICAL REPORT • TYPE 3

122 MAY 2006



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Payer Name






SYNTAX: P0809





CODE DEFINITION





SYNTAX: P0809

IMPLEMENTATION NAME: Payer Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BB • NM1TECHNICAL REPORT • TYPE 3 PAYER NAME

MAY 2006 123

N3PARTY LOCATION 005010X223 • 837 • 2010BB • N3PAYER ADDRESS

SEGMENT DETAIL

453 N3 - PAYER ADDRESSX12 Segment Name: Party Location


Loop: 2010BB — PAYER NAME

Segment Repeat: 1

Usage: SITUATIONAL

792 Situational Rule: Required when the payer address is available and the submitter intendsfor the claim to be printed on paper at the next EDI location (for example, aclearinghouse). If not required by this implementation guide, do not send.


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Payer Address Line



IMPLEMENTATION NAME: Payer Address Line

005010X223 • 837 • 2010BB • N3 ASC X12N • INSURANCE SUBCOMMITTEEPAYER ADDRESS TECHNICAL REPORT • TYPE 3

124 MAY 2006

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010BB • N4PAYER CITY, STATE, ZIP CODE

SEGMENT DETAIL

455 N4 - PAYER CITY, STATE, ZIP CODEX12 Segment Name: Geographic Location






Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Payer City Name


SYNTAX: E0207



IMPLEMENTATION NAME: Payer State Code


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BB • N4TECHNICAL REPORT • TYPE 3 PAYER CITY, STATE, ZIP CODE

MAY 2006 125

tdrinkard

Text Box

Change the usage to Situational with the following Situational Rule: "Required when the payer address is available and the submitter intends for the claim to be printed on paper at the next EDI location (for example, a clearinghouse). If not required by this implementation guide, do not send."

tdrinkard

Highlight



IMPLEMENTATION NAME: Payer Postal Zone or ZIP Code



SYNTAX: C0704











005010X223 • 837 • 2010BB • N4 ASC X12N • INSURANCE SUBCOMMITTEEPAYER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

126 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2010BB • REFPAYER SECONDARY IDENTIFICATION

SEGMENT DETAIL

108 REF - PAYER SECONDARY IDENTIFICATIONX12 Segment Name: Reference Information




Segment Repeat: 3

Usage: SITUATIONAL


456 TR3 Example: REF✽ FY✽ 435261708~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION


1442 This code is only allowed when the National PlanIdentifier is reported in NM109 of this loop.







ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BB • REFTECHNICAL REPORT • TYPE 3 PAYER SECONDARY IDENTIFICATION

MAY 2006 127


SYNTAX: R0203

IMPLEMENTATION NAME: Payer Additional Identifier



005010X223 • 837 • 2010BB • REF ASC X12N • INSURANCE SUBCOMMITTEEPAYER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

128 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2010BB • REFBILLING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

414 REF - BILLING PROVIDER SECONDARYIDENTIFICATION





Segment Repeat: 1

Usage: SITUATIONAL

1486 Situational Rule: Required prior to the mandated NPI Implementation Date when anadditional identification number is necessary for the receiver to identifythe provider.ORRequired on or after the mandated NPI Implementation Date when NM109in Loop 2010AA is not used and an identification number other than theNPI is necessary for the receiver to identify the provider.If not required by this implementation guide, do not send.

369 TR3 Example: REF✽ G2✽ 12345~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

G2 Provider Commercial Number

1464 This code designates a proprietary provider numberfor the destination payer identified in the PayerName loop, Loop ID-2010BB, associated with thisclaim. This is to be used by all payers including:Medicare, Medicaid, Blue Cross, etc.

LU Location Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010BB • REFTECHNICAL REPORT • TYPE 3 BILLING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 129


SYNTAX: R0203

IMPLEMENTATION NAME: Billing Provider Secondary Identifier



005010X223 • 837 • 2010BB • REF ASC X12N • INSURANCE SUBCOMMITTEEBILLING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

130 MAY 2006

HLHIERARCHICAL LEVEL 005010X223 • 837 • 2000C • HLPATIENT HIERARCHICAL LEVEL

SEGMENT DETAIL

113 HL - PATIENT HIERARCHICAL LEVELX12 Segment Name: Hierarchical Level




Loop: 2000C — PATIENT HIERARCHICAL LEVEL Loop Repeat: >1

Segment Repeat: 1

Usage: SITUATIONAL

115 Situational Rule: Required when the patient is a dependent of the subscriber identified inLoop ID-2000B and cannot be uniquely identified to the payer using thesubscriber’s identifier in the Subscriber Level. If not required by thisimplementation guide, do not send.

116 TR3 Notes: 1. There are no HLs subordinate to the Patient HL.

117 2. If a patient is a dependent of a subscriber and can be uniquelyidentified to the payer by a unique Identification Number, then thepatient is considered the subscriber and is to be identified in theSubscriber Level.

114 TR3 Example: HL✽ 3✽ 2✽ 23✽ 0~

DIAGRAM

HL01 628 HL02 734 HL03 735 HL04 736



Child Code ~

M 1 AN 1/12 O 1 AN 1/12 M 1 ID 1/2 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000C • HLTECHNICAL REPORT • TYPE 3 PATIENT HIERARCHICAL LEVEL

MAY 2006 131

REQUIRED HL02 734 Hierarchical Parent ID Number O 1 AN 1/12Identification number of the next higher hierarchical data segment that the datasegment being described is subordinate to

COMMENT: HL02 identifies the hierarchical ID number of the HL segment to whichthe current HL segment is subordinate.



CODE DEFINITION

23 Dependent

118 The code DEPENDENT conveys that the informationin this HL applies to the patient when the subscriberand the patient are not the same person.

REQUIRED HL04 736 Hierarchical Child Code O 1 ID 1/1Code indicating if there are hierarchical child data segments subordinate to thelevel being described


CODE DEFINITION

0 No Subordinate HL Segment in This HierarchicalStructure.

005010X223 • 837 • 2000C • HL ASC X12N • INSURANCE SUBCOMMITTEEPATIENT HIERARCHICAL LEVEL TECHNICAL REPORT • TYPE 3

132 MAY 2006

PATPATIENT INFORMATION 005010X223 • 837 • 2000C • PATPATIENT INFORMATION

SEGMENT DETAIL

74 PAT - PATIENT INFORMATIONX12 Segment Name: Patient Information

X12 Purpose: To supply patient information

X12 Syntax: 1. P0506If either PAT05 or PAT06 is present, then the other is required.

2. P0708If either PAT07 or PAT08 is present, then the other is required.

Loop: 2000C — PATIENT HIERARCHICAL LEVEL

Segment Repeat: 1

Usage: REQUIRED

474 TR3 Example: PAT✽ 01~

DIAGRAM

PAT01 1069 PAT02 1384 PAT03 584 PAT04 1220 PAT05 1250 PAT06 1251

PAT ✽ IndividualRelat Code

✽ Patient LocCode

✽ EmploymentStatus Code

✽ StudentStatus Code

✽ Date TimeFormat Qual

✽ Date TimePeriod

O 1 ID 2/2 O 1 ID 1/1 O 1 ID 2/2 O 1 ID 1/1 X 1 ID 2/3 X 1 AN 1/35

PAT07 355 PAT08 81 PAT09 1073

✽ Unit/BasisMeas Code

✽ Weight ✽ Yes/No CondResp Code ~

X 1 ID 2/2 X 1 R 1/10 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PAT01 1069 Individual Relationship Code O 1 ID 2/2Code indicating the relationship between two individuals or entities

1289 Specifies the patient’s relationship to the person insured.

CODE DEFINITION

01 Spouse

19 Child

20 Employee

21 Unknown

39 Organ Donor

40 Cadaver Donor

53 Life Partner

G8 Other RelationshipNOT USED PAT02 1384 Patient Location Code O 1 ID 1/1

NOT USED PAT03 584 Employment Status Code O 1 ID 2/2

NOT USED PAT04 1220 Student Status Code O 1 ID 1/1

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2000C • PATTECHNICAL REPORT • TYPE 3 PATIENT INFORMATION

MAY 2006 133

NOT USED PAT05 1250 Date Time Period Format Qualifier X 1 ID 2/3

NOT USED PAT06 1251 Date Time Period X 1 AN 1/35

NOT USED PAT07 355 Unit or Basis for Measurement Code X 1 ID 2/2

NOT USED PAT08 81 Weight X 1 R 1/10

NOT USED PAT09 1073 Yes/No Condition or Response Code O 1 ID 1/1

005010X223 • 837 • 2000C • PAT ASC X12N • INSURANCE SUBCOMMITTEEPATIENT INFORMATION TECHNICAL REPORT • TYPE 3

134 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2010CA • NM1PATIENT NAME

SEGMENT DETAIL

121 NM1 - PATIENT NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2010CA — PATIENT NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

120 TR3 Example: NM1✽ QC✽ 1✽ DOE✽ SALLY✽ J~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

QC PatientREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION

1 Person

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010CA • NM1TECHNICAL REPORT • TYPE 3 PATIENT NAME

MAY 2006 135


SYNTAX: C1203

IMPLEMENTATION NAME: Patient Last Name


266 SITUATIONAL RULE: Required when the person has a first name. If notrequired by this implementation guide, do not send.

IMPLEMENTATION NAME: Patient First Name


1170 SITUATIONAL RULE: Required when the middle name or initial of theperson is needed to identify the individual. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Patient Middle Name or Initial



268 SITUATIONAL RULE: Required when the name suffix is needed to identifythe individual. If not required by this implementation guide, do notsend.

IMPLEMENTATION NAME: Patient Name Suffix






005010X223 • 837 • 2010CA • NM1 ASC X12N • INSURANCE SUBCOMMITTEEPATIENT NAME TECHNICAL REPORT • TYPE 3

136 MAY 2006

N3PARTY LOCATION 005010X223 • 837 • 2010CA • N3PATIENT ADDRESS

SEGMENT DETAIL

123 N3 - PATIENT ADDRESSX12 Segment Name: Party Location


Loop: 2010CA — PATIENT NAME

Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Patient Address Line



IMPLEMENTATION NAME: Patient Address Line

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010CA • N3TECHNICAL REPORT • TYPE 3 PATIENT ADDRESS

MAY 2006 137

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2010CA • N4PATIENT CITY, STATE, ZIP CODE

SEGMENT DETAIL

124 N4 - PATIENT CITY, STATE, ZIP CODEX12 Segment Name: Geographic Location






Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Patient City Name


SYNTAX: E0207



IMPLEMENTATION NAME: Patient State Code


005010X223 • 837 • 2010CA • N4 ASC X12N • INSURANCE SUBCOMMITTEEPATIENT CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

138 MAY 2006



IMPLEMENTATION NAME: Patient Postal Zone or ZIP Code



SYNTAX: C0704











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010CA • N4TECHNICAL REPORT • TYPE 3 PATIENT CITY, STATE, ZIP CODE

MAY 2006 139

DMGDEMOGRAPHIC INFORMATION 005010X223 • 837 • 2010CA • DMGPATIENT DEMOGRAPHIC INFORMATION

SEGMENT DETAIL

125 DMG - PATIENT DEMOGRAPHICINFORMATION

X12 Segment Name: Demographic Information

X12 Purpose: To supply demographic information

X12 Syntax: 1. P0102If either DMG01 or DMG02 is present, then the other is required.

2. P1011If either DMG10 or DMG11 is present, then the other is required.

3. C1105If DMG11 is present, then DMG05 is required.


Segment Repeat: 1

Usage: REQUIRED

94 TR3 Example: DMG✽ D8✽ 19690815✽ M~

DIAGRAM

DMG01 1250 DMG02 1251 DMG03 1068 DMG04 1067 DMG05 C056 DMG06 1066

DMG ✽ Date TimeFormat Qual ✽ Date Time

Period ✽ GenderCode ✽ Marital

Status Code ✽ Comp Raceor Ethn Inf ✽ Citizenship

Status CodeX 1 ID 2/3 X 1 AN 1/35 O 1 ID 1/1 O 1 ID 1/1 X 10 O 1 ID 1/2

DMG07 26 DMG08 659 DMG09 380 DMG10 1270 DMG11 1271

✽ CountryCode ✽ Basis of

Verif Code ✽ Quantity ✽ Code ListQual Code ✽ Industry

Code ~

O 1 ID 2/3 O 1 ID 1/2 O 1 R 1/15 X 1 ID 1/3 X 1 AN 1/30

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED DMG01 1250 Date Time Period Format Qualifier X 1 ID 2/3Code indicating the date format, time format, or date and time format

SYNTAX: P0102

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDDREQUIRED DMG02 1251 Date Time Period X 1 AN 1/35


SYNTAX: P0102

SEMANTIC: DMG02 is the date of birth.

IMPLEMENTATION NAME: Patient Birth Date

005010X223 • 837 • 2010CA • DMG ASC X12N • INSURANCE SUBCOMMITTEEPATIENT DEMOGRAPHIC INFORMATION TECHNICAL REPORT • TYPE 3

140 MAY 2006

REQUIRED DMG03 1068 Gender Code O 1 ID 1/1Code indicating the sex of the individual

IMPLEMENTATION NAME: Patient Gender Code

CODE DEFINITION

F Female

M Male

U UnknownNOT USED DMG04 1067 Marital Status Code O 1 ID 1/1

NOT USED DMG05 C056 COMPOSITE RACE OR ETHNICITYINFORMATION

X10

NOT USED DMG06 1066 Citizenship Status Code O 1 ID 1/2

NOT USED DMG07 26 Country Code O 1 ID 2/3

NOT USED DMG08 659 Basis of Verification Code O 1 ID 1/2

NOT USED DMG09 380 Quantity O 1 R 1/15

NOT USED DMG10 1270 Code List Qualifier Code X 1 ID 1/3

NOT USED DMG11 1271 Industry Code X 1 AN 1/30

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2010CA • DMGTECHNICAL REPORT • TYPE 3 PATIENT DEMOGRAPHIC INFORMATION

MAY 2006 141

REFREFERENCE INFORMATION 005010X223 • 837 • 2010CA • REFPROPERTY AND CASUALTY CLAIM NUMBER

SEGMENT DETAIL

444 REF - PROPERTY AND CASUALTY CLAIMNUMBER





Segment Repeat: 1

Usage: SITUATIONAL

446 Situational Rule: Required when the services included in this claim are to be considered aspart of a property and casualty claim. If not required by thisimplementation guide, do not send.

447 TR3 Notes: 1. This is a property and casualty payer-assigned claim number.Providers receive this number from the property and casualty payerduring eligibility determinations or some other communication withthat payer. See Section 1.4.2, Property and Casualty, for additionalinformation about property and casualty claims.

448 2. This segment is not a HIPAA requirement as of this writing.

445 TR3 Example: REF✽ Y4✽ 4445555~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

Y4 Agency Claim NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Property Casualty Claim Number



005010X223 • 837 • 2010CA • REF ASC X12N • INSURANCE SUBCOMMITTEEPROPERTY AND CASUALTY CLAIM NUMBER TECHNICAL REPORT • TYPE 3

142 MAY 2006

CLMHEALTH CLAIM 005010X223 • 837 • 2300 • CLMCLAIM INFORMATION

SEGMENT DETAIL

138 CLM - CLAIM INFORMATIONX12 Segment Name: Health Claim

X12 Purpose: To specify basic data about the claim

Loop: 2300 — CLAIM INFORMATION Loop Repeat: 100

Segment Repeat: 1

Usage: REQUIRED

139 TR3 Notes: 1. The developers of this implementation guide recommend that tradingpartners limit the size of the transaction (ST-SE envelope) to amaximum of 5000 CLM segments. There is no recommended limit tothe number of ST-SE transactions within a GS-GE or ISA-IEA. Willingtrading partners can agree to set limits higher.

140 2. For purposes of this documentation, the claim detail information ispresented only in the dependent level. Specific claim detailinformation can be given in either the subscriber or the dependenthierarchical level. Because of this, the claim information is said to“float.” Claim information is positioned in the same hierarchical levelthat describes its owner-participant, either the subscriber or thedependent. In other words, the claim information, Loop ID-2300, isplaced following Loop ID-2010BB in the Subscriber Hierarchical Level(HL) when patient information is sent in Loop ID-2010BA of theSubscriber HL. Claim information is placed in the Patient HL when thepatient information is sent in Loop ID-2010CA of the Patient HL. Whenthe patient is the subscriber or is considered to be the subscriber,Loop ID-2000C and Loop ID-2010CA are not sent. SeeSubscriber/Patient HL Segment explanation in section 1.4.3.2.2.1 fordetails.

1298 TR3 Example: CLM✽ 12345656✽ 500✽✽✽ 11:A:1✽ Y✽ A✽ Y✽ I~

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • CLMTECHNICAL REPORT • TYPE 3 CLAIM INFORMATION

MAY 2006 143

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CLM✽12345656✽500✽✽✽11:A:1✽Y✽A✽Y✽I**********08~

DIAGRAM

CLM01 1028 CLM02 782 CLM03 1032 CLM04 1343 CLM05 C023 CLM06 1073

CLM ✽ Claim SubmtIdentifier ✽ Monetary

Amount ✽ Claim FileInd Code ✽ Non-Inst

Claim Code ✽ Health CareServ Loc. ✽ Yes/No Cond

Resp CodeM 1 AN 1/38 O 1 R 1/18 O 1 ID 1/2 O 1 ID 1/2 O 1 O 1 ID 1/1

CLM07 1359 CLM08 1073 CLM09 1363 CLM10 1351 CLM11 C024 CLM12 1366

✽ ProviderAccept Code ✽ Yes/No Cond

Resp Code ✽ Release ofInfo Code ✽ Patient Sig

Source Code ✽ RelatedCauses Info ✽ Special

Prog CodeO 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/1 O 1 O 1 ID 2/3

CLM13 1073 CLM14 1338 CLM15 1073 CLM16 1360 CLM17 1029 CLM18 1073

✽ Yes/No CondResp Code ✽ Level of

Serv Code ✽ Yes/No CondResp Code ✽ Provider

Agree Code ✽ ClaimStatus Code ✽ Yes/No Cond

Resp CodeO 1 ID 1/1 O 1 ID 1/3 O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/2 O 1 ID 1/1

CLM19 1383 CLM20 1514

✽ Claim SubmtReason Code ✽ Delay

Reason Code ~

O 1 ID 2/2 O 1 ID 1/2

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CLM01 1028 Claim Submitter’s Identifier M 1 AN 1/38Identifier used to track a claim from creation by the health care provider throughpayment

IMPLEMENTATION NAME: Patient Control Number

479 The number that the submitter transmits in this position is echoedback to the submitter in the 835 and other transactions. Thispermits the submitter to use the value in this field as a key in thesubmitter’s system to match the claim to the payment informationreturned in the 835 transaction. The two recommended identifiersare either the Patient Account Number or the Claim Number in thebilling submitter’s patient management system. The developers ofthis implementation guide strongly recommend that submitters useunique numbers for this field for each individual claim.

480 When Loop ID-2010AC is present, CLM01 represents thesubrogated Medicaid agency’s claim number (ICN/DCN) from theiroriginal 835 CLP07 - Payer Claim Control Number. See Section1.4.1.4 of the front matter for a description of post paymentrecovery claims for subrogated Medicaid agencies.

143 The maximum number of characters to be supported for this field is‘20’. Characters beyond the maximum are not required to be storednor returned by any 837-receiving system.

005010X223 • 837 • 2300 • CLM ASC X12N • INSURANCE SUBCOMMITTEECLAIM INFORMATION TECHNICAL REPORT • TYPE 3

144 MAY 2006

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REQUIRED CLM02 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: CLM02 is the total amount of all submitted charges of service segmentsfor this claim.

IMPLEMENTATION NAME: Total Claim Charge Amount

144 The Total Claim Charge Amount must be greater than or equal tozero.

1299 The total claim charge amount must balance to the sum of allservice line charge amounts reported in the Institutional ServiceLine (SV2) segments for this claim.

NOT USED CLM03 1032 Claim Filing Indicator Code O 1 ID 1/2

NOT USED CLM04 1343 Non-Institutional Claim Type Code O 1 ID 1/2

REQUIRED CLM05 C023 HEALTH CARE SERVICE LOCATIONINFORMATION

O 1

To provide information that identifies the place of service or the type of bill relatedto the location at which a health care service was rendered

REQUIRED CLM05 - 1 1331 Facility Code Value M AN 1/2Code identifying where services were, or may be, performed; the firstand second positions of the Uniform Bill Type Code for InstitutionalServices or the Place of Service Codes for Professional or DentalServices.

IMPLEMENTATION NAME: Facility Type Code

REQUIRED CLM05 - 2 1332 Facility Code Qualifier O ID 1/2Code identifying the type of facility referenced

SEMANTIC:

C023-02 qualifies C023-01 and C023-03.

CODE DEFINITION

A Uniform Billing Claim Form Bill Type

CODE SOURCE 236: Uniform Billing Claim Form Bill TypeREQUIRED CLM05 - 3 1325 Claim Frequency Type Code O ID 1/1

Code specifying the frequency of the claim; this is the third position ofthe Uniform Billing Claim Form Bill Type

IMPLEMENTATION NAME: Claim Frequency Code

CODE SOURCE 235: Claim Frequency Type Code

NOT USED CLM06 1073 Yes/No Condition or Response Code O 1 ID 1/1


MAY 2006 145

REQUIRED CLM07 1359 Provider Accept Assignment Code O 1 ID 1/1Code indicating whether the provider accepts assignment

IMPLEMENTATION NAME: Assignment or Plan Participation Code

1559 Within this element the context of the word assignment is related tothe relationship between the provider and the payer. This is NOTthe field for reporting whether the patient has or has not assignedbenefits to the provider. The benefit assignment indicator is inCLM08.

CODE DEFINITION

A Assigned

1560 Required when the provider accepts assignmentand/or has a participation agreement with thedestination payer.ORRequired when the provider does not acceptassignment and/or have a participation agreement,but is advising the payer to adjudicate this specificclaim under participating provider benefits asallowed under certain plans.

B Assignment Accepted on Clinical Lab Services Only

1561 Required when the provider accepts assignment forClinical Lab Services only.

C Not Assigned

1562 Required when neither codes ‘A’ nor ‘B’ apply.REQUIRED CLM08 1073 Yes/No Condition or Response Code O 1 ID 1/1

Code indicating a Yes or No condition or response

SEMANTIC: CLM08 is assignment of benefits indicator. A “Y” value indicatesinsured or authorized person authorizes benefits to be assigned to the provider;an “N” value indicates benefits have not been assigned to the provider.

IMPLEMENTATION NAME: Benefits Assignment Certification Indicator

486 This element answers the question whether or not the insured hasauthorized the plan to remit payment directly to the provider.

CODE DEFINITION

N No

W Not Applicable

1563 Use code ‘W’ when the patient refuses to assignbenefits.

Y Yes


146 MAY 2006

REQUIRED CLM09 1363 Release of Information Code O 1 ID 1/1Code indicating whether the provider has on file a signed statement by the patientauthorizing the release of medical data to other organizations

487 The Release of Information response is limited to the informationcarried in this claim.

CODE DEFINITION

I Informed Consent to Release Medical Informationfor Conditions or Diagnoses Regulated by FederalStatutes

488 Required when the provider has not collected asignature AND state or federal laws do not require asignature be collected.

Y Yes, Provider has a Signed Statement PermittingRelease of Medical Billing Data Related to a Claim

489 Required when the provider has collected asignature.ORRequired when state or federal laws require asignature be collected.

NOT USED CLM10 1351 Patient Signature Source Code O 1 ID 1/1

NOT USED CLM11 C024 RELATED CAUSES INFORMATION O 1

NOT USED CLM12 1366 Special Program Code O 1 ID 2/3


NOT USED CLM14 1338 Level of Service Code O 1 ID 1/3


NOT USED CLM16 1360 Provider Agreement Code O 1 ID 1/1

NOT USED CLM17 1029 Claim Status Code O 1 ID 1/2


NOT USED CLM19 1383 Claim Submission Reason Code O 1 ID 2/2

SITUATIONAL CLM20 1514 Delay Reason Code O 1 ID 1/2Code indicating the reason why a request was delayed

493 SITUATIONAL RULE: Required when the claim is submitted late (pastcontracted date of filing limitations). If not required by thisimplementation guide, do not send.

CODE DEFINITION

1 Proof of Eligibility Unknown or Unavailable

2 Litigation

3 Authorization Delays

4 Delay in Certifying Provider

5 Delay in Supplying Billing Forms

6 Delay in Delivery of Custom-made Appliances

7 Third Party Processing Delay

8 Delay in Eligibility Determination

9 Original Claim Rejected or Denied Due to a ReasonUnrelated to the Billing Limitation Rules

10 Administration Delay in the Prior Approval Process


MAY 2006 147

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Change usage of CLM19 to Required. Add an Implementation Name of "Predetermination of Benefits Code" (same implementation name as used in the Dental Guide 005010X224) Add value 08 to CLM19. It is the only allowed value.

11 Other

15 Natural Disaster


148 MAY 2006

DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2300 • DTPDISCHARGE HOUR

SEGMENT DETAIL

151 DTP - DISCHARGE HOURX12 Segment Name: Date or Time or Period

X12 Purpose: To specify any or all of a date, a time, or a time period

Loop: 2300 — CLAIM INFORMATION

Segment Repeat: 1

Usage: SITUATIONAL

1301 Situational Rule: Required on all final inpatient claims. If not required by thisimplementation guide, do not send.

153 TR3 Example: DTP✽ 096✽ TM✽ 1130~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251

DTP ✽ Date/TimeQualifier ✽ Date Time

Format Qual ✽ Date TimePeriod ~

M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED DTP01 374 Date/Time Qualifier M 1 ID 3/3Code specifying type of date or time, or both date and time

IMPLEMENTATION NAME: Date Time Qualifier

CODE DEFINITION

096 DischargeREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3

Code indicating the date format, time format, or date and time format

SEMANTIC: DTP02 is the date or time or period format that will appear in DTP03.

CODE DEFINITION

TM Time Expressed in Format HHMMREQUIRED DTP03 1251 Date Time Period M 1 AN 1/35


IMPLEMENTATION NAME: Discharge Time

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • DTPTECHNICAL REPORT • TYPE 3 DISCHARGE HOUR

MAY 2006 149

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Delete this segment. It is not applicable to the standalone predetermination guide.

DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2300 • DTPSTATEMENT DATES

SEGMENT DETAIL

156 DTP - STATEMENT DATESX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: REQUIRED

155 TR3 Example: DTP✽ 434✽ RD8✽ 20041209-20041214~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

434 StatementREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



CODE DEFINITION

RD8 Range of Dates Expressed in Format CCYYMMDD-CCYYMMDD

157 Use RD8 to indicate the from and through date ofthe statement. When the statement is for a singledate of service, the from and through date are thesame.

REQUIRED DTP03 1251 Date Time Period M 1 AN 1/35Expression of a date, a time, or range of dates, times or dates and times

IMPLEMENTATION NAME: Statement From and To Date

005010X223 • 837 • 2300 • DTP ASC X12N • INSURANCE SUBCOMMITTEESTATEMENT DATES TECHNICAL REPORT • TYPE 3

150 MAY 2006

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DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2300 • DTPADMISSION DATE/HOUR

SEGMENT DETAIL

158 DTP - ADMISSION DATE/HOURX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: SITUATIONAL

1305 Situational Rule: Required on inpatient claims.If not required by this implementation guide, do not send.

159 TR3 Example: DTP✽ 435✽ DT✽ 200410131242~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

435 AdmissionREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



1578 Selection of the appropriate qualifier is designated by the NUBCBilling Manual.

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDD

DT Date and Time Expressed in FormatCCYYMMDDHHMM


IMPLEMENTATION NAME: Admission Date and Hour

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • DTPTECHNICAL REPORT • TYPE 3 ADMISSION DATE/HOUR

MAY 2006 151

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DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2300 • DTPDATE - REPRICER RECEIVED DATE

SEGMENT DETAIL

1505 DTP - DATE - REPRICER RECEIVED DATEX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: SITUATIONAL

1503 Situational Rule: Required when a repricer is passing the claim onto the payer. If notrequired by this implementation guide, do not send.

1504 TR3 Example: DTP✽ 050✽ D8✽ 20051030~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

050 ReceivedREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



CODE DEFINITION

D8 Date Expressed in Format CCYYMMDDREQUIRED DTP03 1251 Date Time Period M 1 AN 1/35


IMPLEMENTATION NAME: Repricer Received Date

005010X223 • 837 • 2300 • DTP ASC X12N • INSURANCE SUBCOMMITTEEDATE - REPRICER RECEIVED DATE TECHNICAL REPORT • TYPE 3

152 MAY 2006

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Replace the Situational Rule with: "Required when a repricer is passing the predetermination request to a payer. If not required by this implementation guide, do not send.

CL1CLAIM CODES 005010X223 • 837 • 2300 • CL1INSTITUTIONAL CLAIM CODE

SEGMENT DETAIL

171 CL1 - INSTITUTIONAL CLAIM CODEX12 Segment Name: Claim Codes

X12 Purpose: To supply information specific to hospital claims


Segment Repeat: 1

Usage: REQUIRED

170 TR3 Example: CL1✽ 1✽ 7✽ 30~

DIAGRAM

CL101 1315 CL102 1314 CL103 1352 CL104 1345

CL1 ✽ AdmissionType Code ✽ Admission

Source Code ✽ PatientStatus Code ✽ Nurse Home

Status Code ~

O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/2 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


SITUATIONAL CL101 1315 Admission Type Code O 1 ID 1/1Code indicating the priority of this admission

172 SITUATIONAL RULE: Required when patient is being admitted for inpatientservices. If not required by this implementation guide, do not send.

CODE SOURCE 231: Admission Type Code

SITUATIONAL CL102 1314 Admission Source Code O 1 ID 1/1Code indicating the source of this admission

173 SITUATIONAL RULE: Required for all inpatient and outpatient services. Ifnot required by this implementation guide, do not send.

CODE SOURCE 230: Admission Source Code

REQUIRED CL103 1352 Patient Status Code O 1 ID 1/2Code indicating patient status as of the “statement covers through date”

CODE SOURCE 239: Patient Status Code

NOT USED CL104 1345 Nursing Home Residential Status Code O 1 ID 1/1

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • CL1TECHNICAL REPORT • TYPE 3 INSTITUTIONAL CLAIM CODE

MAY 2006 153

PWKPAPERWORK 005010X223 • 837 • 2300 • PWKCLAIM SUPPLEMENTAL INFORMATION

SEGMENT DETAIL

175 PWK - CLAIM SUPPLEMENTAL INFORMATIONX12 Segment Name: Paperwork

X12 Purpose: To identify the type or transmission or both of paperwork or supportinginformation

X12 Syntax: 1. P0506If either PWK05 or PWK06 is present, then the other is required.


Segment Repeat: 10

Usage: SITUATIONAL

176 Situational Rule: Required when there is a paper attachment following this claim.ORRequired when attachments are sent electronically (PWK02 = EL) but aretransmitted in another functional group (for example, 275) rather than bypaper. PWK06 is then used to identify the attached electronicdocumentation. The number in PWK06 is carried in the TRN of theelectronic attachment.ORRequired when the provider deems it necessary to identify additionalinformation that is being held at the provider’s office and is available uponrequest by the payer (or appropriate entity), but the information is notbeing submitted with the claim. Use the value of “AA” in PWK02 to conveythis specific use of the PWK segment.If not required by this implementation guide, do not send.

177 TR3 Example: PWK✽ OZ✽ BM✽✽✽ AC✽ DMN0012~

DIAGRAM

PWK01 755 PWK02 756 PWK03 757 PWK04 98 PWK05 66 PWK06 67

PWK ✽ Report TypeCode ✽ Report

Transm Code ✽ ReportCopies Need ✽ Entity ID

Code ✽ ID CodeQualifier ✽ ID

CodeM 1 ID 2/2 O 1 ID 1/2 O 1 N0 1/2 O 1 ID 2/3 X 1 ID 1/2 X 1 AN 2/80

PWK07 352 PWK08 C002 PWK09 1525

✽ Description ✽ ActionsIndicated ✽ Request

Categ Code ~

O 1 AN 1/80 O 1 O 1 ID 1/2

005010X223 • 837 • 2300 • PWK ASC X12N • INSURANCE SUBCOMMITTEECLAIM SUPPLEMENTAL INFORMATION TECHNICAL REPORT • TYPE 3

154 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PWK01 755 Report Type Code M 1 ID 2/2Code indicating the title or contents of a document, report or supporting item

IMPLEMENTATION NAME: Attachment Report Type Code

CODE DEFINITION

03 Report Justifying Treatment Beyond UtilizationGuidelines

04 Drugs Administered

05 Treatment Diagnosis

06 Initial Assessment

07 Functional Goals

08 Plan of Treatment

09 Progress Report

10 Continued Treatment

11 Chemical Analysis

13 Certified Test Report

15 Justification for Admission

21 Recovery Plan

A3 Allergies/Sensitivities Document

A4 Autopsy Report

AM Ambulance Certification

AS Admission Summary

B2 Prescription

B3 Physician Order

B4 Referral Form

BR Benchmark Testing Results

BS Baseline

BT Blanket Test Results

CB Chiropractic Justification

CK Consent Form(s)

CT Certification

D2 Drug Profile Document

DA Dental Models

DB Durable Medical Equipment Prescription

DG Diagnostic Report

DJ Discharge Monitoring Report

DS Discharge Summary

EB Explanation of Benefits (Coordination of Benefits orMedicare Secondary Payor)

HC Health Certificate

HR Health Clinic Records

I5 Immunization Record

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • PWKTECHNICAL REPORT • TYPE 3 CLAIM SUPPLEMENTAL INFORMATION

MAY 2006 155

IR State School Immunization Records

LA Laboratory Results

M1 Medical Record Attachment

MT Models

NN Nursing Notes

OB Operative Note

OC Oxygen Content Averaging Report

OD Orders and Treatments Document

OE Objective Physical Examination (including vitalsigns) Document

OX Oxygen Therapy Certification

OZ Support Data for Claim

P4 Pathology Report

P5 Patient Medical History Document

PE Parenteral or Enteral Certification

PN Physical Therapy Notes

PO Prosthetics or Orthotic Certification

PQ Paramedical Results

PY Physician’s Report

PZ Physical Therapy Certification

RB Radiology Films

RR Radiology Reports

RT Report of Tests and Analysis Report

RX Renewable Oxygen Content Averaging Report

SG Symptoms Document

V5 Death Notification

XP PhotographsREQUIRED PWK02 756 Report Transmission Code O 1 ID 1/2

Code defining timing, transmission method or format by which reports are to besent

IMPLEMENTATION NAME: Attachment Transmission Code

CODE DEFINITION

AA Available on Request at Provider Site

179 This means that the additional information is notbeing sent with the claim at this time. Instead, it isavailable to the payer (or appropriate entity) at theirrequest.

BM By Mail

EL Electronically Only

180 Indicates that the attachment is being transmitted ina separate X12 functional group.

EM E-Mail

FT File Transfer

1523 Required when the actual attachment is maintainedby an attachment warehouse or similar vendor.

005010X223 • 837 • 2300 • PWK ASC X12N • INSURANCE SUBCOMMITTEECLAIM SUPPLEMENTAL INFORMATION TECHNICAL REPORT • TYPE 3

156 MAY 2006

FX By FaxNOT USED PWK03 757 Report Copies Needed O 1 N0 1/2

NOT USED PWK04 98 Entity Identifier Code O 1 ID 2/3

SITUATIONAL PWK05 66 Identification Code Qualifier X 1 ID 1/2Code designating the system/method of code structure used for IdentificationCode (67)

SYNTAX: P0506

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a codenumber.

181 SITUATIONAL RULE: Required when PWK02 = “BM”, “EL”, “EM”, “FX” or“FT”. If not required by this implementation guide, do not send.

CODE DEFINITION

AC Attachment Control NumberSITUATIONAL PWK06 67 Identification Code X 1 AN 2/80


SYNTAX: P0506


IMPLEMENTATION NAME: Attachment Control Number

1494 PWK06 is used to identify the attached electronic documentation.The number in PWK06 is carried in the TRN of the electronicattachment.

1495 For the purpose of this implementation, the maximum field lengthis 50.

NOT USED PWK07 352 Description O 1 AN 1/80

NOT USED PWK08 C002 ACTIONS INDICATED O 1

NOT USED PWK09 1525 Request Category Code O 1 ID 1/2

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • PWKTECHNICAL REPORT • TYPE 3 CLAIM SUPPLEMENTAL INFORMATION

MAY 2006 157

CN1CONTRACT INFORMATION 005010X223 • 837 • 2300 • CN1CONTRACT INFORMATION

SEGMENT DETAIL

550 CN1 - CONTRACT INFORMATIONX12 Segment Name: Contract Information

X12 Purpose: To specify basic data about the contract or contract line item


Segment Repeat: 1

Usage: SITUATIONAL

552 Situational Rule: Required when the submitter is contractually obligated to supply thisinformation on post-adjudicated claims. If not required by thisimplementation guide, do not send.

551 TR3 Notes: 1. The developers of this implementation guide note that the CN1segment is for use only for post-adjudicated claims, which do notmeet the definition of a health care claim under HIPAA. Consequently,at the time of this writing, the CN1 segment is for non-HIPAA use only.

549 TR3 Example: CN1✽ 02✽ 550~

DIAGRAM

CN101 1166 CN102 782 CN103 332 CN104 127 CN105 338 CN106 799

CN1 ✽ ContractType Code ✽ Monetary

Amount ✽ Allow/ChrgPercent ✽ Reference

Ident ✽ Terms DiscPercent ✽ Version

ID ~

M 1 ID 2/2 O 1 R 1/18 O 1 R 1/6 O 1 AN 1/50 O 1 R 1/6 O 1 AN 1/30

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CN101 1166 Contract Type Code M 1 ID 2/2Code identifying a contract type

CODE DEFINITION

01 Diagnosis Related Group (DRG)

02 Per Diem

03 Variable Per Diem

04 Flat

05 Capitated

06 Percent

09 OtherSITUATIONAL CN102 782 Monetary Amount O 1 R 1/18

Monetary amount

SEMANTIC: CN102 is the contract amount.

553 SITUATIONAL RULE: Required when the provider is required by contractto supply this information on the claim. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Contract Amount

005010X223 • 837 • 2300 • CN1 ASC X12N • INSURANCE SUBCOMMITTEECONTRACT INFORMATION TECHNICAL REPORT • TYPE 3

158 MAY 2006

SITUATIONAL CN103 332 Percent, Decimal Format O 1 R 1/6Percent given in decimal format (e.g., 0.0 through 100.0 represents 0% through100%)

SEMANTIC: CN103 is the allowance or charge percent.


IMPLEMENTATION NAME: Contract Percentage

SITUATIONAL CN104 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: CN104 is the contract code.


IMPLEMENTATION NAME: Contract Code

SITUATIONAL CN105 338 Terms Discount Percent O 1 R 1/6Terms discount percentage, expressed as a percent, available to the purchaser ifan invoice is paid on or before the Terms Discount Due Date


IMPLEMENTATION NAME: Terms Discount Percentage

SITUATIONAL CN106 799 Version Identifier O 1 AN 1/30Revision level of a particular format, program, technique or algorithm

SEMANTIC: CN106 is an additional identifying number for the contract.


IMPLEMENTATION NAME: Contract Version Identifier

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • CN1TECHNICAL REPORT • TYPE 3 CONTRACT INFORMATION

MAY 2006 159

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2300 • AMTPATIENT ESTIMATED AMOUNT DUE

SEGMENT DETAIL

186 AMT - PATIENT ESTIMATED AMOUNT DUEX12 Segment Name: Monetary Amount Information

X12 Purpose: To indicate the total monetary amount


Segment Repeat: 1

Usage: SITUATIONAL

187 Situational Rule: Required when the Patient Responsibility Amount is applicable to thisclaim.If not required by this implementation guide, do not send.

185 TR3 Example: AMT✽ F3✽ 123~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478

AMT ✽ Amount QualCode ✽ Monetary

Amount ✽ Cred/DebitFlag Code ~

M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED AMT01 522 Amount Qualifier Code M 1 ID 1/3Code to qualify amount

CODE DEFINITION

F3 Patient Responsibility - EstimatedREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Patient Responsibility Amount

NOT USED AMT03 478 Credit/Debit Flag Code O 1 ID 1/1

005010X223 • 837 • 2300 • AMT ASC X12N • INSURANCE SUBCOMMITTEEPATIENT ESTIMATED AMOUNT DUE TECHNICAL REPORT • TYPE 3

160 MAY 2006

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Delete this AMT segment.

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFSERVICE AUTHORIZATION EXCEPTION CODE

SEGMENT DETAIL

563 REF - SERVICE AUTHORIZATION EXCEPTIONCODE





Segment Repeat: 1

Usage: SITUATIONAL

565 Situational Rule: Required when mandated by government law or regulation to obtainauthorization for specific service(s) but, for the reasons listed in REF02,the service was performed without obtaining the authorization. If notrequired by this implementation guide, do not send.

564 TR3 Example: REF✽ 4N✽ 1~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

4N Special Payment Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Service Authorization Exception Code

566 Allowable values for this element are:1 Immediate/Urgent Care2 Services Rendered in a Retroactive Period3 Emergency Care4 Client has Temporary Medicaid5 Request from County for Second Opinion to Determine

if Recipient Can Work6 Request for Override Pending7 Special Handling

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 SERVICE AUTHORIZATION EXCEPTION CODE

MAY 2006 161



005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEESERVICE AUTHORIZATION EXCEPTION CODE TECHNICAL REPORT • TYPE 3

162 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFREFERRAL NUMBER

SEGMENT DETAIL

1496 REF - REFERRAL NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

576 Situational Rule: Required when a referral number is assigned by the payer or UtilizationManagement Organization (UMO)ANDa referral is involved.If not required by this implementation guide, do not send.

1320 TR3 Notes: 1. Numbers at this position apply to the entire claim unless they areoverridden in the REF segment in Loop ID-2400. A referenceidentification is considered to be overridden if the value in REF01 isthe same in both the Loop ID-2300 REF segment and the Loop ID-2400REF segment. In that case, the Loop ID-2400 REF applies only to thatspecific line.

948 TR3 Example: REF✽ 9F✽ 12345~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9F Referral NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Referral Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 REFERRAL NUMBER

MAY 2006 163

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFPRIOR AUTHORIZATION

SEGMENT DETAIL

575 REF - PRIOR AUTHORIZATIONX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

1321 Situational Rule: Required when an authorization number is assigned by the payer or UMOANDthe services on this claim were preauthorized.If not required by this implementation guide, do not send.

1319 TR3 Notes: 1. Generally, preauthorization numbers are assigned by the payer orUMO to authorize a service prior to its being performed. The UMO(Utilization Management Organization) is generally the entityempowered to make a decision regarding the outcome of a healthservices review or the owner of information. The prior authorizationnumber carried in this REF is specific to the destination payerreported in the Loop ID-2010BB. If other payers have similar numbersfor this claim, report that information in the Loop ID-2330 loop REFwhich holds that payer’s information.

1320 2. Numbers at this position apply to the entire claim unless they areoverridden in the REF segment in Loop ID-2400. A referenceidentification is considered to be overridden if the value in REF01 isthe same in both the Loop ID-2300 REF segment and the Loop ID-2400REF segment. In that case, the Loop ID-2400 REF applies only to thatspecific line.


DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

G1 Prior Authorization Number

005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEEPRIOR AUTHORIZATION TECHNICAL REPORT • TYPE 3

164 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Prior Authorization Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 PRIOR AUTHORIZATION

MAY 2006 165

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFPAYER CLAIM CONTROL NUMBER

SEGMENT DETAIL

581 REF - PAYER CLAIM CONTROL NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

580 Situational Rule: Required when CLM05-3 (Claim Frequency Code) indicates this claim is areplacement or void to a previously adjudicated claim. If not required bythis implementation guide, do not send.

582 TR3 Notes: 1. This information is specific to the destination payer reported in LoopID-2010BB.

579 TR3 Example: REF✽ F8✽ R555588~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

F8 Original Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Payer Claim Control Number



005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEEPAYER CLAIM CONTROL NUMBER TECHNICAL REPORT • TYPE 3

166 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFREPRICED CLAIM NUMBER

SEGMENT DETAIL

589 REF - REPRICED CLAIM NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

590 Situational Rule: Required when this information is deemed necessary by the repricer. Thesegment is not completed by providers. The information is completed byrepricers only. If not required by this implementation guide, do not send.


588 TR3 Example: REF✽ 9A✽ RJ55555~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9A Repriced Claim Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Repriced Claim Reference Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 REPRICED CLAIM NUMBER

MAY 2006 167

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFADJUSTED REPRICED CLAIM NUMBER

SEGMENT DETAIL

592 REF - ADJUSTED REPRICED CLAIM NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL



591 TR3 Example: REF✽ 9C✽ RP44444444~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9C Adjusted Repriced Claim Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Adjusted Repriced Claim Reference Number



005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEEADJUSTED REPRICED CLAIM NUMBER TECHNICAL REPORT • TYPE 3

168 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFINVESTIGATIONAL DEVICE EXEMPTION NUMBER

SEGMENT DETAIL

594 REF - INVESTIGATIONAL DEVICEEXEMPTION NUMBER





Segment Repeat: 5

Usage: SITUATIONAL

595 Situational Rule: Required when claim involves a Food and Drug Administration (FDA)assigned investigational device exemption (IDE) number. When more thanone IDE applies, they must be split into separate claims. If not required bythis implementation guide, do not send.

593 TR3 Example: REF✽ LX✽ 432907~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

LX Qualified Products ListREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Investigational Device Exemption Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 INVESTIGATIONAL DEVICE EXEMPTION NUMBER

MAY 2006 169

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFCLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

SEGMENT DETAIL

596 REF - CLAIM IDENTIFIER FORTRANSMISSION INTERMEDIARIES





Segment Repeat: 1

Usage: SITUATIONAL

598 Situational Rule: Required when this information is deemed necessary by transmissionintermediaries (Automated Clearinghouses, and others) who need toattach their own unique claim number. If not required by thisimplementation guide, do not send.

599 TR3 Notes: 1. Although this REF is supplied for transmission intermediaries toattach their own unique claim number to a claim, 837-recipients arenot required under HIPAA to return this number in any HIPAAtransaction. Trading partners may voluntarily agree to this interactionif they wish.

597 TR3 Example: REF✽ D9✽ TJ98UU321~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



600 Number assigned by clearinghouse, van, etc.

CODE DEFINITION

D9 Claim Number

005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEECLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES TECHNICAL REPORT • TYPE 3

170 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Value Added Network Trace Number

601 The value carried in this element is limited to a maximum of 20positions.



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 CLAIM IDENTIFIER FOR TRANSMISSION INTERMEDIARIES

MAY 2006 171

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFAUTO ACCIDENT STATE

SEGMENT DETAIL

1499 REF - AUTO ACCIDENT STATEX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

1501 Situational Rule: Required when the services reported on this claim are related to an autoaccident and the accident occurred in a country or location that has astate, province, or sub-country code named in code source 22. If notrequired by this implementation guide, do not send.

1500 TR3 Example: REF✽ LU✽ MD~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

LU Location NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Auto Accident State or Province Code

1502 Values in this field must be valid codes found in code source 22.



005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEEAUTO ACCIDENT STATE TECHNICAL REPORT • TYPE 3

172 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFMEDICAL RECORD NUMBER

SEGMENT DETAIL

193 REF - MEDICAL RECORD NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

195 Situational Rule: Required when the provider needs to identify for future inquiries, theactual medical record of the patient identified in either Loop ID-2010BA orLoop ID-2010CA for this episode of care. If not required by thisimplementation guide, do not send.

194 TR3 Example: REF✽ EA✽ 44444TH56~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

EA Medical Record Identification NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Medical Record Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 MEDICAL RECORD NUMBER

MAY 2006 173

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFDEMONSTRATION PROJECT IDENTIFIER

SEGMENT DETAIL

602 REF - DEMONSTRATION PROJECTIDENTIFIER





Segment Repeat: 1

Usage: SITUATIONAL

604 Situational Rule: Required when it is necessary to identify claims which are atypical inways such as content, purpose, and/or payment, as could be the case fora demonstration or other special project, or a clinical trial. If not requiredby this implementation guide, do not send.

603 TR3 Example: REF✽ P4✽ THJ1222~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

P4 Project CodeREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Demonstration Project Identifier



005010X223 • 837 • 2300 • REF ASC X12N • INSURANCE SUBCOMMITTEEDEMONSTRATION PROJECT IDENTIFIER TECHNICAL REPORT • TYPE 3

174 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2300 • REFPEER REVIEW ORGANIZATION (PRO) APPROVAL NUMBER

SEGMENT DETAIL

1334 REF - PEER REVIEW ORGANIZATION (PRO)APPROVAL NUMBER





Segment Repeat: 1

Usage: SITUATIONAL

1335 Situational Rule: Required when an external Peer Review Organization assigns an ApprovalNumber to services deemed medically necessary by that organization. Ifnot required by this implementation guide, do not send.

1336 TR3 Example: REF✽ G4✽ 284746~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

G4 Peer Review Organization (PRO) Approval NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Peer Review Authorization Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • REFTECHNICAL REPORT • TYPE 3 PEER REVIEW ORGANIZATION (PRO) APPROVAL NUMBER

MAY 2006 175

K3FILE INFORMATION 005010X223 • 837 • 2300 • K3FILE INFORMATION

SEGMENT DETAIL

609 K3 - FILE INFORMATIONX12 Segment Name: File Information

X12 Purpose: To transmit a fixed-format record or matrix contents


Segment Repeat: 10

Usage: SITUATIONAL

200 Situational Rule: Required when ALL of the following conditions are met:• A regulatory agency concludes it must use the K3 to meet an emergency legislative requirement;• The administering regulatory agency or other state organization has completed each one of the following steps: contacted the X12N workgroup, requested a review of the K3 data requirement to ensure there is not an existing method within the implementation guide to meet this requirement• X12N determines that there is no method to meet the requirement.If not required by this implementation guide, do not send.

201 TR3 Notes: 1. At the time of publication of this implementation, K3 segments haveno specific use. The K3 segment is expected to be used only whennecessary to meet the unexpected data requirement of a legislativeauthority. Before this segment can be used : - The X12N Health Care Claim workgroup must conclude there is noother available option in the implementation guide to meet theemergency legislative requirement.- The requestor must submit a proposal for approval accompanied bythe relevant business documentation to the X12N Health Care Claimworkgroup chairs and receive approval for the request.Upon review of the request, X12N will issue an approval or denialdecision to the requesting entity. Approved usage(s) of the K3segment will be reviewed by the X12N Health Care Claim workgroup todevelop a permanent change to include the business case in futuretransaction implementations.

202 2. Only when all of the requirements above have been met, may theregulatory agency require the temporary use of the K3 segment.

203 3. X12N will submit the necessary data maintenance and refer therequest to the appropriate data content committee(s).

199 TR3 Example: K3✽ STATE DATA REQUIREMENT~

DIAGRAM

K301 449 K302 1333 K303 C001

K3 ✽ Fixed FormInformation ✽ Record

Format Code ✽ CompositeUnit of Mea ~

M 1 AN 1/80 O 1 ID 1/2 O 1

005010X223 • 837 • 2300 • K3 ASC X12N • INSURANCE SUBCOMMITTEEFILE INFORMATION TECHNICAL REPORT • TYPE 3

176 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED K301 449 Fixed Format Information M 1 AN 1/80Data in fixed format agreed upon by sender and receiver

NOT USED K302 1333 Record Format Code O 1 ID 1/2

NOT USED K303 C001 COMPOSITE UNIT OF MEASURE O 1

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • K3TECHNICAL REPORT • TYPE 3 FILE INFORMATION

MAY 2006 177

NTENOTE/SPECIAL INSTRUCTION 005010X223 • 837 • 2300 • NTECLAIM NOTE

SEGMENT DETAIL

204 NTE - CLAIM NOTEX12 Segment Name: Note/Special Instruction

X12 Purpose: To transmit information in a free-form format, if necessary, for comment orspecial instruction

X12 Comments: 1. The NTE segment permits free-form information/data which, under ANSIX12 standard implementations, is not machine processible. The use of theNTE segment should therefore be avoided, if at all possible, in anautomated environment.


Segment Repeat: 10

Usage: SITUATIONAL

207 Situational Rule: Required when in the judgment of the provider, the information is neededto substantiate the medical treatment and is not supported elsewherewithin the claim data set.ORRequired when in the judgment of the provider, narrative information fromthe forms “Home Health Certification and Plan of Treatment” or “MedicalUpdate and Patient Information” is needed to substantiate home healthservices.If not required by this implementation guide, do not send.

206 TR3 Notes: 1. The developers of this implementation guide discourage usingnarrative information within the 837. Trading partners who usenarrative information with claims are strongly encouraged to codifythat information within the X12 environment.

1337 TR3 Example: NTE✽ NTR✽ PATIENT REQUIRES TUBE FEEDING~

DIAGRAM

NTE01 363 NTE02 352

NTE ✽ Note RefCode ✽ Description

~

O 1 ID 3/3 M 1 AN 1/80

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED NTE01 363 Note Reference Code O 1 ID 3/3Code identifying the functional area or purpose for which the note applies

CODE DEFINITION

ALG Allergies

DCP Goals, Rehabilitation Potential, or Discharge Plans

DGN Diagnosis Description

DME Durable Medical Equipment (DME) and Supplies

005010X223 • 837 • 2300 • NTE ASC X12N • INSURANCE SUBCOMMITTEECLAIM NOTE TECHNICAL REPORT • TYPE 3

178 MAY 2006

MED Medications

NTR Nutritional Requirements

ODT Orders for Disciplines and Treatments

RHB Functional Limitations, Reason Homebound, or Both

RLH Reasons Patient Leaves Home

RNH Times and Reasons Patient Not at Home

SET Unusual Home, Social Environment, or Both

SFM Safety Measures

SPT Supplementary Plan of Treatment

UPI Updated InformationREQUIRED NTE02 352 Description M 1 AN 1/80

A free-form description to clarify the related data elements and their content

IMPLEMENTATION NAME: Claim Note Text

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • NTETECHNICAL REPORT • TYPE 3 CLAIM NOTE

MAY 2006 179

NTENOTE/SPECIAL INSTRUCTION 005010X223 • 837 • 2300 • NTEBILLING NOTE

SEGMENT DETAIL

1338 NTE - BILLING NOTEX12 Segment Name: Note/Special Instruction




Segment Repeat: 1

Usage: SITUATIONAL

611 Situational Rule: Required when in the judgment of the provider, the information is neededto substantiate the medical treatment and is not supported elsewherewithin the claim data set.If not required by this implementation guide, do not send.

1339 TR3 Example: NTE✽ ADD✽ NO LIABILITY, PATIENT FELL AT HOME~

DIAGRAM

NTE01 363 NTE02 352


~

O 1 ID 3/3 M 1 AN 1/80

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

ADD Additional InformationREQUIRED NTE02 352 Description M 1 AN 1/80


IMPLEMENTATION NAME: Billing Note Text

005010X223 • 837 • 2300 • NTE ASC X12N • INSURANCE SUBCOMMITTEEBILLING NOTE TECHNICAL REPORT • TYPE 3

180 MAY 2006

CRCCONDITIONS INDICATOR 005010X223 • 837 • 2300 • CRCEPSDT REFERRAL

SEGMENT DETAIL

645 CRC - EPSDT REFERRALX12 Segment Name: Conditions Indicator

X12 Purpose: To supply information on conditions


Segment Repeat: 1

Usage: SITUATIONAL

647 Situational Rule: Required on Early & Periodic Screening, Diagnosis, and Treatment(EPSDT) claims when the screening service is being billed in this claim. Ifnot required by this implementation guide, do not send.

646 TR3 Example: CRC✽ ZZ✽ Y✽ ST~

DIAGRAM

CRC01 1136 CRC02 1073 CRC03 1321 CRC04 1321 CRC05 1321 CRC06 1321

CRC ✽ CodeCategory ✽ Yes/No Cond

Resp Code ✽ CertificateCond Code ✽ Certificate

Cond Code ✽ CertificateCond Code ✽ Certificate

Cond CodeM 1 ID 2/2 M 1 ID 1/1 M 1 ID 2/3 O 1 ID 2/3 O 1 ID 2/3 O 1 ID 2/3

CRC07 1321

✽ CertificateCond Code ~

O 1 ID 2/3

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CRC01 1136 Code Category M 1 ID 2/2Specifies the situation or category to which the code applies

SEMANTIC: CRC01 qualifies CRC03 through CRC07.

IMPLEMENTATION NAME: Code Qualifier

CODE DEFINITION

ZZ Mutually Defined

648 EPSDT Screening referral information.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • CRCTECHNICAL REPORT • TYPE 3 EPSDT REFERRAL

MAY 2006 181

REQUIRED CRC02 1073 Yes/No Condition or Response Code M 1 ID 1/1Code indicating a Yes or No condition or response

SEMANTIC: CRC02 is a Certification Condition Code applies indicator. A “Y” valueindicates the condition codes in CRC03 through CRC07 apply; an “N” valueindicates the condition codes in CRC03 through CRC07 do not apply.

IMPLEMENTATION NAME: Certification Condition Code Applies Indicator

649 The response answers the question: Was an EPSDT referral givento the patient?

CODE DEFINITION

N No

650 If no, then choose “NU” in CRC03 indicating noreferral given.

Y YesREQUIRED CRC03 1321 Condition Indicator M 1 ID 2/3

Code indicating a condition

651 The codes for CRC03 also can be used for CRC04 through CRC05.

CODE DEFINITION

AV Available - Not Used

652 Patient refused referral.

NU Not Used

653 This conditioner indicator must be used when thesubmitter answers “N” in CRC02.

S2 Under Treatment

654 Patient is currently under treatment for referreddiagnostic or corrective health problem.

ST New Services Requested

655 Patient is referred to another provider for diagnosticor corrective treatment for at least one healthproblem identified during an initial or periodicscreening service (not including dental referrals). OR Patient is scheduled for another appointment withscreening provider for diagnostic or correctivetreatment for at least one health problem identifiedduring an initial or periodic screening service (notincluding dental referrals).

SITUATIONAL CRC04 1321 Condition Indicator O 1 ID 2/3Code indicating a condition

634 SITUATIONAL RULE: Required when a second condition code isnecessary. If not required by this implementation guide, do notsend.

635 Use the codes listed in CRC03.

005010X223 • 837 • 2300 • CRC ASC X12N • INSURANCE SUBCOMMITTEEEPSDT REFERRAL TECHNICAL REPORT • TYPE 3

182 MAY 2006

SITUATIONAL CRC05 1321 Condition Indicator O 1 ID 2/3Code indicating a condition

636 SITUATIONAL RULE: Required when a third condition code is necessary. Ifnot required by this implementation guide, do not send.

635 Use the codes listed in CRC03.

NOT USED CRC06 1321 Condition Indicator O 1 ID 2/3

NOT USED CRC07 1321 Condition Indicator O 1 ID 2/3

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • CRCTECHNICAL REPORT • TYPE 3 EPSDT REFERRAL

MAY 2006 183

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIPRINCIPAL DIAGNOSIS

SEGMENT DETAIL

208 HI - PRINCIPAL DIAGNOSISX12 Segment Name: Health Care Information Codes

X12 Purpose: To supply information related to the delivery of health care


Segment Repeat: 1

Usage: REQUIRED

210 TR3 Notes: 1. Do not transmit the decimal point for ICD codes. The decimal point isimplied.

209 TR3 Example: HI✽ BK:99761~

1516 TR3 Example: HI✽ ABK:T8731~

DIAGRAM

HI01 C022 HI02 C022 HI03 C022 HI04 C022 HI05 C022 HI06 C022

HI ✽ Health CareCode Info. ✽ Health Care

Code Info. ✽ Health CareCode Info. ✽ Health Care


Code Info.M 1 O 1 O 1 O 1 O 1 O 1


✽ Health CareCode Info.





✽ Health CareCode Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED HI01 C022 HEALTH CARE CODE INFORMATION M 1To send health care codes and their associated dates, amounts and quantities

SYNTAX:

P0304If either C02203 or C02204 is present, then the other is required.E0809Only one of C02208 or C02209 may be present.

REQUIRED HI01 - 1 1270 Code List Qualifier Code M ID 1/3Code identifying a specific industry code list

SEMANTIC:

C022-01 qualifies C022-02, C022-04, C022-05, C022-06 and C022-08.

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEPRINCIPAL DIAGNOSIS TECHNICAL REPORT • TYPE 3

184 MAY 2006

CODE DEFINITION

ABK International Classification of Diseases ClinicalModification (ICD-10-CM) Principal Diagnosis

1541 This code set is not allowed for use under HIPAA atthe time of this writing. The qualifier can only beused:If a new rule names the ICD-10-CM as an allowablecode set under HIPAA, ORThe Secretary grants an exception to use the codeset as a pilot project as allowed under the law, ORFor claims which are not covered under HIPAA.

CODE SOURCE 897: International Classification of Diseases, 10thRevision, Clinical Modification (ICD-10-CM)

BK International Classification of Diseases ClinicalModification (ICD-9-CM) Principal Diagnosis


REQUIRED HI01 - 2 1271 Industry Code M AN 1/30Code indicating a code from a specific industry code list

SEMANTIC:

If C022-08 is used, then C022-02 represents the beginning value in arange of codes.

IMPLEMENTATION NAME: Principal Diagnosis Code

NOT USED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3

NOT USED HI01 - 4 1251 Date Time Period X AN 1/35

NOT USED HI01 - 5 782 Monetary Amount O R 1/18

NOT USED HI01 - 6 380 Quantity O R 1/15

NOT USED HI01 - 7 799 Version Identifier O AN 1/30

NOT USED HI01 - 8 1271 Industry Code X AN 1/30

SITUATIONAL HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1Code indicating a Yes or No condition or response

SYNTAX:

E0809

SEMANTIC:

C022-09 is used to identify the diagnosis onset as it relates to thediagnosis reported in C022-02. A “Y” indicates that the onset occurredprior to admission to the hospital; an “N” indicates that the onset didNOT occur prior to admission to the hospital; a “U” indicates that it isunknown whether the onset occurred prior to admission to the hospitalor not.

COMMENTS:

C022-09 would only need to be reported to data collectors requiring thisinformation when C022-01 is “BF” (Diagnosis Code) and range ofdiagnosis codes were NOT given in C022-08.

229 SITUATIONAL RULE: Required as directed by the NUBC billingmanual.

IMPLEMENTATION NAME: Present on Admission Indicator

CODE DEFINITION

N No

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 PRINCIPAL DIAGNOSIS

MAY 2006 185

U Unknown

W Not Applicable

Y YesNOT USED HI02 C022 HEALTH CARE CODE INFORMATION O 1

NOT USED HI03 C022 HEALTH CARE CODE INFORMATION O 1










005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEPRINCIPAL DIAGNOSIS TECHNICAL REPORT • TYPE 3

186 MAY 2006

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIADMITTING DIAGNOSIS

SEGMENT DETAIL

1363 HI - ADMITTING DIAGNOSISX12 Segment Name: Health Care Information Codes



Segment Repeat: 1

Usage: SITUATIONAL

1365 Situational Rule: Required when claim involves an inpatient admission.If not required by this implementation guide, do not send.


213 TR3 Example: HI✽ BJ:99762~

1517 TR3 Example: HI✽ ABJ:T8741~

DIAGRAM







✽ Health CareCode Info. ✽ Health Care



Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 ADMITTING DIAGNOSIS

MAY 2006 187


SEMANTIC:


CODE DEFINITION

ABJ International Classification of Diseases ClinicalModification (ICD-10-CM) Admitting Diagnosis



BJ International Classification of Diseases ClinicalModification (ICD-9-CM) Admitting Diagnosis



SEMANTIC:


IMPLEMENTATION NAME: Admitting Diagnosis Code







NOT USED HI01 - 9 1073 Yes/No Condition or Response Code X ID 1/1












005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEADMITTING DIAGNOSIS TECHNICAL REPORT • TYPE 3

188 MAY 2006

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIPATIENT’S REASON FOR VISIT

SEGMENT DETAIL

215 HI - PATIENT’S REASON FOR VISITX12 Segment Name: Health Care Information Codes



Segment Repeat: 1

Usage: SITUATIONAL

1368 Situational Rule: Required when claim involves outpatient visits. If not required by thisimplementation guide, do not send.


1369 TR3 Example: HI✽ PR:78701~

1518 TR3 Example: HI✽ APR:R110~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 PATIENT’S REASON FOR VISIT

MAY 2006 189


SEMANTIC:


CODE DEFINITION

APR International Classification of Diseases ClinicalModification (ICD-10-CM) Patient’s Reason for Visit



PR International Classification of Diseases ClinicalModification (ICD-9-CM) Patient’s Reason for Visit



SEMANTIC:


IMPLEMENTATION NAME: Patient Reason For Visit








SITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O 1To send health care codes and their associated dates, amounts and quantities

SYNTAX:


217 SITUATIONAL RULE: Required when an additional Patient’s Reason forVisit must be sent and the preceding HI data elements have beenused to report other patient’s reason for visit. If not required by thisimplementation guide, do not send.

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEPATIENT’S REASON FOR VISIT TECHNICAL REPORT • TYPE 3

190 MAY 2006


SEMANTIC:


CODE DEFINITION







SEMANTIC:











SYNTAX:


217 SITUATIONAL RULE: Required when an additional Patient’s Reason forVisit must be sent and the preceding HI data elements have beenused to report other patient’s reason for visit. If not required by thisimplementation guide, do not send.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 PATIENT’S REASON FOR VISIT

MAY 2006 191


SEMANTIC:


CODE DEFINITION







SEMANTIC:



















005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEPATIENT’S REASON FOR VISIT TECHNICAL REPORT • TYPE 3

192 MAY 2006

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIEXTERNAL CAUSE OF INJURY

SEGMENT DETAIL

1370 HI - EXTERNAL CAUSE OF INJURYX12 Segment Name: Health Care Information Codes



Segment Repeat: 1

Usage: SITUATIONAL

220 Situational Rule: Required when an external Cause of Injury is needed to describe an injury,poisoning, or adverse effect. If not required by this implementation guide,do not send.


221 2. In order to fully describe an injury using ICD-10-CM, it will benecessary to report a series of 3 external cause of injury codes.

219 TR3 Example: HI✽ BN:E8660~

1519 TR3 Example: HI✽ ABN:T560X1~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 EXTERNAL CAUSE OF INJURY

MAY 2006 193


SEMANTIC:


CODE DEFINITION

ABN International Classification of Diseases ClinicalModification (ICD-10-CM) External Cause of InjuryCode



BN International Classification of Diseases ClinicalModification (ICD-9-CM) External Cause of InjuryCode (E-codes)



SEMANTIC:


IMPLEMENTATION NAME: External Cause of Injury Code







005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEEXTERNAL CAUSE OF INJURY TECHNICAL REPORT • TYPE 3

194 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable

Y YesSITUATIONAL HI02 C022 HEALTH CARE CODE INFORMATION O 1

To send health care codes and their associated dates, amounts and quantities

SYNTAX:


222 SITUATIONAL RULE: Required when an additional External Cause of Injurymust be sent and the preceding HI data elements have been usedto report other causes of injury. If not required by thisimplementation guide, do not send.


MAY 2006 195


SEMANTIC:


CODE DEFINITION







SEMANTIC:










196 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 197


SEMANTIC:


CODE DEFINITION







SEMANTIC:










198 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 199


SEMANTIC:


CODE DEFINITION







SEMANTIC:










200 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 201


SEMANTIC:


CODE DEFINITION







SEMANTIC:










202 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 203


SEMANTIC:


CODE DEFINITION







SEMANTIC:










204 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 205


SEMANTIC:


CODE DEFINITION







SEMANTIC:










206 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 207


SEMANTIC:


CODE DEFINITION







SEMANTIC:










208 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 209


SEMANTIC:


CODE DEFINITION







SEMANTIC:










210 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 211


SEMANTIC:


CODE DEFINITION







SEMANTIC:










212 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 213


SEMANTIC:


CODE DEFINITION







SEMANTIC:










214 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 215


SEMANTIC:


CODE DEFINITION







SEMANTIC:










216 MAY 2006


SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable

Y Yes


MAY 2006 217

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIDIAGNOSIS RELATED GROUP (DRG) INFORMATION

SEGMENT DETAIL

224 HI - DIAGNOSIS RELATED GROUP (DRG)INFORMATION

X12 Segment Name: Health Care Information Codes



Segment Repeat: 1

Usage: SITUATIONAL

1375 Situational Rule: Required when an inpatient hospital is under DRG contract with a payerand the contract requires the provider to identify the DRG to the payer. Ifnot required by this implementation guide, do not send.

225 TR3 Example: HI✽ DR:123~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

DR Diagnosis Related Group (DRG)

CODE SOURCE 229: Diagnosis Related Group Number (DRG)

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEDIAGNOSIS RELATED GROUP (DRG) INFORMATION TECHNICAL REPORT • TYPE 3

218 MAY 2006


SEMANTIC:


IMPLEMENTATION NAME: Diagnosis Related Group (DRG) Code



















ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 DIAGNOSIS RELATED GROUP (DRG) INFORMATION

MAY 2006 219

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIOTHER DIAGNOSIS INFORMATION

SEGMENT DETAIL

226 HI - OTHER DIAGNOSIS INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

227 Situational Rule: Required when other condition(s) coexist or develop(s) subsequentlyduring the patient’s treatment. If not required by this implementationguide, do not send.


228 TR3 Example: HI✽ BF:4821:::::::N✽ HI✽ BF:25000:::::::Y~

1520 TR3 Example: HI✽ ABF:J151:::::::N✽ ABF:E119:::::::Y~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEOTHER DIAGNOSIS INFORMATION TECHNICAL REPORT • TYPE 3

220 MAY 2006


SEMANTIC:


CODE DEFINITION

ABF International Classification of Diseases ClinicalModification (ICD-10-CM) Diagnosis



BF International Classification of Diseases ClinicalModification (ICD-9-CM) Diagnosis



SEMANTIC:


IMPLEMENTATION NAME: Other Diagnosis








SYNTAX:

E0809

SEMANTIC:


COMMENTS:



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 OTHER DIAGNOSIS INFORMATION

MAY 2006 221


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:


230 SITUATIONAL RULE: Required when it is necessary to report an additionaldiagnosis and the preceding HI data elements have been used toreport other diagnoses. If not required by this implementationguide, do not send.


SEMANTIC:


CODE DEFINITION







SEMANTIC:








222 MAY 2006




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 223


SEMANTIC:


CODE DEFINITION







SEMANTIC:










SYNTAX:

E0809

SEMANTIC:


COMMENTS:




224 MAY 2006


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:








MAY 2006 225




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




226 MAY 2006


SEMANTIC:


CODE DEFINITION







SEMANTIC:










SYNTAX:

E0809

SEMANTIC:


COMMENTS:




MAY 2006 227


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:








228 MAY 2006




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 229


SEMANTIC:


CODE DEFINITION







SEMANTIC:










SYNTAX:

E0809

SEMANTIC:


COMMENTS:




230 MAY 2006


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:








MAY 2006 231




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




232 MAY 2006


SEMANTIC:


CODE DEFINITION







SEMANTIC:










SYNTAX:

E0809

SEMANTIC:


COMMENTS:




MAY 2006 233


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:








234 MAY 2006




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




MAY 2006 235


SEMANTIC:


CODE DEFINITION







SEMANTIC:










SYNTAX:

E0809

SEMANTIC:


COMMENTS:




236 MAY 2006


CODE DEFINITION

N No

U Unknown

W Not Applicable



SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:








MAY 2006 237




SYNTAX:

E0809

SEMANTIC:


COMMENTS:




CODE DEFINITION

N No

U Unknown

W Not Applicable

Y Yes


238 MAY 2006

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIPRINCIPAL PROCEDURE INFORMATION

SEGMENT DETAIL

231 HI - PRINCIPAL PROCEDURE INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 1

Usage: SITUATIONAL

233 Situational Rule: Required on inpatient claims when a procedure was performed. If notrequired by this implementation guide, do not send.


232 TR3 Example: HI✽ BR:3121:D8:20051119~

1521 TR3 Example: HI✽ BBR:0B110F5:D8:20050321~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 PRINCIPAL PROCEDURE INFORMATION

MAY 2006 239


SEMANTIC:


CODE DEFINITION

BBR International Classification of Diseases ClinicalModification (ICD-10-PCS) Principal ProcedureCodes

1542 This code set is not allowed for use under HIPAA atthe time of this writing. The qualifier can only beused:If a new rule names the ICD-10-PCS as an allowablecode set under HIPAA, ORThe Secretary grants an exception to use the codeset as a pilot project as allowed under the law, ORFor claims which are not covered under HIPAA.

CODE SOURCE 896: International Classification of Diseases, 10thRevision, Procedure Coding System (ICD-10-PCS)

BR International Classification of Diseases ClinicalModification (ICD-9-CM) Principal Procedure Codes


CAH Advanced Billing Concepts (ABC) Codes

CODE SOURCE 843: Advanced Billing Concepts (ABC) CodesREQUIRED HI01 - 2 1271 Industry Code M AN 1/30

Code indicating a code from a specific industry code list

SEMANTIC:


IMPLEMENTATION NAME: Principal Procedure Code

REQUIRED HI01 - 3 1250 Date Time Period Format Qualifier X ID 2/3Code indicating the date format, time format, or date and time format

SYNTAX:

P0304

SEMANTIC:

C022-03 is the date format that will appear in C022-04.

CODE DEFINITION

D8 Date Expressed in Format CCYYMMDDREQUIRED HI01 - 4 1251 Date Time Period X AN 1/35


SYNTAX:

P0304

IMPLEMENTATION NAME: Principal Procedure Date






005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEPRINCIPAL PROCEDURE INFORMATION TECHNICAL REPORT • TYPE 3

240 MAY 2006












ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 PRINCIPAL PROCEDURE INFORMATION

MAY 2006 241

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIOTHER PROCEDURE INFORMATION

SEGMENT DETAIL

235 HI - OTHER PROCEDURE INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

236 Situational Rule: Required on inpatient claims when additional procedures must bereported. If not required by this implementation guide, do not send.


237 TR3 Example: HI✽ BQ:3614:D8:20051117✽ BQ:3723:D8:20051119~

1522 TR3 Example: HI✽ BBQ:02139Y3:D8:20050321✽ BBQ:4A025N8:D8:20050310~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:


005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEOTHER PROCEDURE INFORMATION TECHNICAL REPORT • TYPE 3

242 MAY 2006


SEMANTIC:


CODE DEFINITION

BBQ International Classification of Diseases ClinicalModification (ICD-10-PCS) Other Procedure Codes



BQ International Classification of Diseases ClinicalModification (ICD-9-CM) Other Procedure Codes



SEMANTIC:


IMPLEMENTATION NAME: Procedure Code


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304

IMPLEMENTATION NAME: Procedure Date






ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 OTHER PROCEDURE INFORMATION

MAY 2006 243


SYNTAX:


238 SITUATIONAL RULE: Required when it is necessary to report an additionalprocedure and the preceding HI data elements have been used toreport other procedures. If not required by this implementationguide, do not send.


SEMANTIC:


CODE DEFINITION







SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



244 MAY 2006

REQUIRED HI02 - 4 1251 Date Time Period X AN 1/35Expression of a date, a time, or range of dates, times or dates and times

SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:




MAY 2006 245


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION





246 MAY 2006




SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




MAY 2006 247


SEMANTIC:


CODE DEFINITION







SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








248 MAY 2006


SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



MAY 2006 249


SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:




250 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION





MAY 2006 251




SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




252 MAY 2006


SEMANTIC:


CODE DEFINITION







SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








MAY 2006 253


SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



254 MAY 2006


SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION







SEMANTIC:




MAY 2006 255


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION





256 MAY 2006




SEMANTIC:




SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








MAY 2006 257

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIOCCURRENCE SPAN INFORMATION

SEGMENT DETAIL

239 HI - OCCURRENCE SPAN INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

241 Situational Rule: Required when there is an Occurrence Span Code that applies to thisclaim. If not required by this implementation guide, do not send.

240 TR3 Example: HI✽ BI:70:RD8:20051202-20051212✽ BI:74:RD8:20051214-20051216~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

BI Occurrence Span

CODE SOURCE 132: National Uniform Billing Committee (NUBC)Codes


SEMANTIC:


IMPLEMENTATION NAME: Occurrence Span Code

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEOCCURRENCE SPAN INFORMATION TECHNICAL REPORT • TYPE 3

258 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304

IMPLEMENTATION NAME: Occurrence Span Code Date







SYNTAX:


242 SITUATIONAL RULE: Required when it is necessary to report an additionaloccurrence span code and the preceding HI data elements havebeen used to report other occurrence span codes. If not requiredby this implementation guide, do not send.


SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 OCCURRENCE SPAN INFORMATION

MAY 2006 259


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




260 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




MAY 2006 261


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




262 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




MAY 2006 263


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




264 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




MAY 2006 265


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




266 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




MAY 2006 267


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




268 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BI Occurrence Span



SEMANTIC:




MAY 2006 269


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








270 MAY 2006

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIOCCURRENCE INFORMATION

SEGMENT DETAIL

243 HI - OCCURRENCE INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

244 Situational Rule: Required when there is a Occurrence Code that applies to this claim. If notrequired by this implementation guide, do not send.

245 TR3 Example: HI✽ BH:42:D8:20051208✽ BH:A3:D8:20051203~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:


IMPLEMENTATION NAME: Occurrence Code

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 OCCURRENCE INFORMATION

MAY 2006 271


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304

IMPLEMENTATION NAME: Occurrence Code Date







SYNTAX:


246 SITUATIONAL RULE: Required when it is necessary to report an additionaloccurrence code and the preceding HI data elements have beenused to report other occurrence codes. If not required by thisimplementation guide, do not send.


SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:



005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEOCCURRENCE INFORMATION TECHNICAL REPORT • TYPE 3

272 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




MAY 2006 273


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




274 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




MAY 2006 275


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




276 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




MAY 2006 277


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




278 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




MAY 2006 279


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




280 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




MAY 2006 281


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








SYNTAX:




SEMANTIC:


CODE DEFINITION

BH Occurrence



SEMANTIC:




282 MAY 2006


SYNTAX:

P0304

SEMANTIC:


CODE DEFINITION



SYNTAX:

P0304








MAY 2006 283

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HIVALUE INFORMATION

SEGMENT DETAIL

247 HI - VALUE INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

248 Situational Rule: Required when there is a Value Code that applies to this claim. If notrequired by this implementation guide, do not send.

249 TR3 Example: HI✽ BE:08::1740✽ BE:A7::940~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:


IMPLEMENTATION NAME: Value Code

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEEVALUE INFORMATION TECHNICAL REPORT • TYPE 3

284 MAY 2006



REQUIRED HI01 - 5 782 Monetary Amount O R 1/18Monetary amount

IMPLEMENTATION NAME: Value Code Amount






SYNTAX:


251 SITUATIONAL RULE: Required when it is necessary to report an additionalvalue code and the preceding HI data elements have been used toreport other value codes. If not required by this implementationguide, do not send.


SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 VALUE INFORMATION

MAY 2006 285


SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












SYNTAX:




286 MAY 2006


SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



MAY 2006 287


SEMANTIC:












SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:









288 MAY 2006





SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












SYNTAX:




MAY 2006 289


SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



290 MAY 2006


SEMANTIC:












SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:









MAY 2006 291





SYNTAX:




SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












SYNTAX:




292 MAY 2006


SEMANTIC:


CODE DEFINITION

BE Value



SEMANTIC:












MAY 2006 293

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HICONDITION INFORMATION

SEGMENT DETAIL

252 HI - CONDITION INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

253 Situational Rule: Required when there is a Condition Code that applies to this claim. If notrequired by this implementation guide, do not send.

254 TR3 Example: HI✽ BG:17✽ BG:67~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:


IMPLEMENTATION NAME: Condition Code

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEECONDITION INFORMATION TECHNICAL REPORT • TYPE 3

294 MAY 2006









SYNTAX:


255 SITUATIONAL RULE: Required when it is necessary to report an additionalcondition code and the preceding HI data elements have been usedto report other condition codes. If not required by thisimplementation guide, do not send.


SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:










ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 CONDITION INFORMATION

MAY 2006 295


SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











SYNTAX:




296 MAY 2006


SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:






MAY 2006 297







SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











298 MAY 2006


SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











SYNTAX:




MAY 2006 299


SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:






300 MAY 2006







SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











MAY 2006 301


SYNTAX:




SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











SYNTAX:




302 MAY 2006


SEMANTIC:


CODE DEFINITION

BG Condition



SEMANTIC:











MAY 2006 303

HIHEALTH CARE INFORMATION CODES 005010X223 • 837 • 2300 • HITREATMENT CODE INFORMATION

SEGMENT DETAIL

1377 HI - TREATMENT CODE INFORMATIONX12 Segment Name: Health Care Information Codes



Segment Repeat: 2

Usage: SITUATIONAL

1378 Situational Rule: Required when Home Health Agencies need to report Plan of Treatmentinformation under various payer contracts. If not required by thisimplementation guide, do not send.

1379 TR3 Example: HI✽ TC:A01~

DIAGRAM










Code Info. ~

O 1 O 1 O 1 O 1 O 1 O 1

ELEMENT DETAIL

USAGEREF.DES.



SYNTAX:



SEMANTIC:


CODE DEFINITION

TC Treatment Codes

CODE SOURCE 359: Treatment Codes

005010X223 • 837 • 2300 • HI ASC X12N • INSURANCE SUBCOMMITTEETREATMENT CODE INFORMATION TECHNICAL REPORT • TYPE 3

304 MAY 2006


SEMANTIC:


IMPLEMENTATION NAME: Treatment Code









SYNTAX:


1380 SITUATIONAL RULE: Required when it is necessary to report an additionaltreatment code and the preceding HI data elements have been usedto report other treatment codes. If not required by thisimplementation guide, do not send.


SEMANTIC:


CODE DEFINITION

TC Treatment Codes

CODE SOURCE 359: Treatment CodesREQUIRED HI02 - 2 1271 Industry Code M AN 1/30


SEMANTIC:










ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HITECHNICAL REPORT • TYPE 3 TREATMENT CODE INFORMATION

MAY 2006 305


SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




306 MAY 2006


SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:







MAY 2006 307






SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




308 MAY 2006


SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:







MAY 2006 309






SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




310 MAY 2006


SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:






MAY 2006 311







SYNTAX:




SEMANTIC:


CODE DEFINITION

TC Treatment Codes



SEMANTIC:











312 MAY 2006

HCPHEALTH CARE PRICING 005010X223 • 837 • 2300 • HCPCLAIM PRICING/REPRICING INFORMATION

SEGMENT DETAIL

666 HCP - CLAIM PRICING/REPRICINGINFORMATION

X12 Segment Name: Health Care Pricing

X12 Purpose: To specify pricing or repricing information about a health care claim or line item

X12 Syntax: 1. R0113At least one of HCP01 or HCP13 is required.

2. P0910If either HCP09 or HCP10 is present, then the other is required.



Segment Repeat: 1

Usage: SITUATIONAL



667 2. For capitated encounters, pricing or repricing information usually isnot applicable and is provided to qualify other information within theclaim.

665 TR3 Example: HCP✽ 03✽ 100✽ 10✽ RPO12345~

DIAGRAM

HCP01 1473 HCP02 782 HCP03 782 HCP04 127 HCP05 118 HCP06 127

HCP ✽ PricingMethodology ✽ Monetary

Amount ✽ MonetaryAmount ✽ Reference

Ident ✽ Rate ✽ ReferenceIdent

X 1 ID 2/2 O 1 R 1/18 O 1 R 1/18 O 1 AN 1/50 O 1 R 1/9 O 1 AN 1/50


✽ MonetaryAmount ✽ Product/

Service ID ✽ Prod/ServID Qual ✽ Product/

Service ID ✽ Unit/BasisMeas Code ✽ Quantity

O 1 R 1/18 O 1 AN 1/48 X 1 ID 2/2 X 1 AN 1/48 X 1 ID 2/2 X 1 R 1/15

HCP13 901 HCP14 1526 HCP15 1527

✽ RejectReason Code ✽ Policy Comp

Code ✽ ExceptionCode ~

X 1 ID 2/2 O 1 ID 1/2 O 1 ID 1/2

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2300 • HCPTECHNICAL REPORT • TYPE 3 CLAIM PRICING/REPRICING INFORMATION

MAY 2006 313

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED HCP01 1473 Pricing Methodology X 1 ID 2/2Code specifying pricing methodology at which the claim or line item has beenpriced or repriced

SYNTAX: R0113

668 Specific code use is determined by Trading Partner Agreement dueto the variances in contracting policies in the industry.

CODE DEFINITION

00 Zero Pricing (Not Covered Under Contract)

01 Priced as Billed at 100%

02 Priced at the Standard Fee Schedule

03 Priced at a Contractual Percentage

04 Bundled Pricing

05 Peer Review Pricing

06 Per Diem Pricing

07 Flat Rate Pricing

08 Combination Pricing

09 Maternity Pricing

10 Other Pricing

11 Lower of Cost

12 Ratio of Cost

13 Cost Reimbursed

14 Adjustment PricingREQUIRED HCP02 782 Monetary Amount O 1 R 1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.

IMPLEMENTATION NAME: Repriced Allowed Amount

SITUATIONAL HCP03 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: HCP03 is the savings amount.

590 SITUATIONAL RULE: Required when this information is deemed necessaryby the repricer. The segment is not completed by providers. Theinformation is completed by repricers only. If not required by thisimplementation guide, do not send.

IMPLEMENTATION NAME: Repriced Saving Amount

582 This information is specific to the destination payer reported inLoop ID-2010BB.

005010X223 • 837 • 2300 • HCP ASC X12N • INSURANCE SUBCOMMITTEECLAIM PRICING/REPRICING INFORMATION TECHNICAL REPORT • TYPE 3

314 MAY 2006

SITUATIONAL HCP04 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: HCP04 is the repricing organization identification number.


IMPLEMENTATION NAME: Repricing Organization Identifier


SITUATIONAL HCP05 118 Rate O 1 R 1/9Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.


IMPLEMENTATION NAME: Repricing Per Diem or Flat Rate Amount



SEMANTIC: HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will containdifferent values from the original submitted values.


IMPLEMENTATION NAME: Repriced Approved DRG Code



SEMANTIC: HCP07 is the approved DRG amount.


IMPLEMENTATION NAME: Repriced Approved Amount



MAY 2006 315

SITUATIONAL HCP08 234 Product/Service ID O 1 AN 1/48Identifying number for a product or service

SEMANTIC: HCP08 is the approved revenue code.


IMPLEMENTATION NAME: Repriced Approved Revenue Code


NOT USED HCP09 235 Product/Service ID Qualifier X 1 ID 2/2

NOT USED HCP10 234 Product/Service ID X 1 AN 1/48

SITUATIONAL HCP11 355 Unit or Basis for Measurement Code X 1 ID 2/2Code specifying the units in which a value is being expressed, or manner in whicha measurement has been taken

SYNTAX: P1112

1383 SITUATIONAL RULE: Required when HCP12 exists. If not required by thisimplementation guide, do not send.

CODE DEFINITION

DA Days

UN UnitSITUATIONAL HCP12 380 Quantity X 1 R 1/15

Numeric value of quantity

SYNTAX: P1112

SEMANTIC: HCP12 is the approved service units or inpatient days.


IMPLEMENTATION NAME: Repriced Approved Service Unit Count


847 The maximum length for this field is 8 digits excluding the decimal.When a decimal is used, the maximum number of digits allowed tothe right of the decimal is three.


316 MAY 2006

SITUATIONAL HCP13 901 Reject Reason Code X 1 ID 2/2Code assigned by issuer to identify reason for rejection

SYNTAX: R0113

SEMANTIC: HCP13 is the rejection message returned from the third partyorganization.



CODE DEFINITION

T1 Cannot Identify Provider as TPO (Third PartyOrganization) Participant

T2 Cannot Identify Payer as TPO (Third PartyOrganization) Participant

T3 Cannot Identify Insured as TPO (Third PartyOrganization) Participant

T4 Payer Name or Identifier Missing

T5 Certification Information Missing

T6 Claim does not contain enough information for re-pricing

SITUATIONAL HCP14 1526 Policy Compliance Code O 1 ID 1/2Code specifying policy compliance



CODE DEFINITION

1 Procedure Followed (Compliance)

2 Not Followed - Call Not Made (Non-Compliance CallNot Made)

3 Not Medically Necessary (Non-Compliance Non-Medically Necessary)

4 Not Followed Other (Non-Compliance Other)

5 Emergency Admit to Non-Network Hospital


MAY 2006 317

SITUATIONAL HCP15 1527 Exception Code O 1 ID 1/2Code specifying the exception reason for consideration of out-of-network healthcare services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.



CODE DEFINITION

1 Non-Network Professional Provider in NetworkHospital

2 Emergency Care

3 Services or Specialist not in Network

4 Out-of-Service Area

5 State Mandates

6 Other


318 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310A • NM1ATTENDING PROVIDER NAME

SEGMENT DETAIL

1384 NM1 - ATTENDING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Loop 2310 contains information about the rendering, referring, or attendingprovider.




Loop: 2310A — ATTENDING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

262 Situational Rule: Required when the claim contains any services other than non-scheduledtransportation claims. If not required by this implementation guide, do notsend.

263 TR3 Notes: 1. The Attending Provider is the individual who has overall responsibilityfor the patient’s medical care and treatment reported in this claim.

264 TR3 Example: NM1✽ 71✽ 1✽ JONES✽ JOHN✽✽✽✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

71 Attending Physician

1506 When used, the term physician is any type ofprovider filling this role.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310A • NM1TECHNICAL REPORT • TYPE 3 ATTENDING PROVIDER NAME

MAY 2006 319



CODE DEFINITION

1 PersonREQUIRED NM103 1035 Name Last or Organization Name X 1 AN 1/60


SYNTAX: C1203

IMPLEMENTATION NAME: Attending Provider Last Name



IMPLEMENTATION NAME: Attending Provider First Name



IMPLEMENTATION NAME: Attending Provider Middle Name or Initial




IMPLEMENTATION NAME: Attending Provider Name Suffix

005010X223 • 837 • 2310A • NM1 ASC X12N • INSURANCE SUBCOMMITTEEATTENDING PROVIDER NAME TECHNICAL REPORT • TYPE 3

320 MAY 2006


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Attending Provider Primary Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310A • NM1TECHNICAL REPORT • TYPE 3 ATTENDING PROVIDER NAME

MAY 2006 321

PRVPROVIDER INFORMATION 005010X223 • 837 • 2310A • PRVATTENDING PROVIDER SPECIALTY INFORMATION

SEGMENT DETAIL

1507 PRV - ATTENDING PROVIDER SPECIALTYINFORMATION

X12 Segment Name: Provider Information

X12 Purpose: To specify the identifying characteristics of a provider

X12 Syntax: 1. P0203If either PRV02 or PRV03 is present, then the other is required.

Loop: 2310A — ATTENDING PROVIDER NAME

Segment Repeat: 1

Usage: SITUATIONAL

1508 Situational Rule: Required when adjudication of the destination payer, or any subsequentpayer listed on this claim, is known to be impacted by the attendingprovider taxonomy code. If not required by this implementation guide, donot send.

1509 TR3 Example: PRV✽ AT✽ PXC✽ 208D00000X~

DIAGRAM

PRV01 1221 PRV02 128 PRV03 127 PRV04 156 PRV05 C035 PRV06 1223

PRV ✽ ProviderCode ✽ Reference

Ident Qual ✽ ReferenceIdent ✽ State or

Prov Code ✽ ProviderSpec. Inf. ✽ Provider

Org Code ~

M 1 ID 1/3 X 1 ID 2/3 X 1 AN 1/50 O 1 ID 2/2 O 1 O 1 ID 3/3

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PRV01 1221 Provider Code M 1 ID 1/3Code identifying the type of provider

CODE DEFINITION

AT AttendingREQUIRED PRV02 128 Reference Identification Qualifier X 1 ID 2/3

Code qualifying the Reference Identification

SYNTAX: P0203

CODE DEFINITION

PXC Health Care Provider Taxonomy Code

CODE SOURCE 682: Health Care Provider TaxonomyREQUIRED PRV03 127 Reference Identification X 1 AN 1/50


SYNTAX: P0203

IMPLEMENTATION NAME: Provider Taxonomy Code

NOT USED PRV04 156 State or Province Code O 1 ID 2/2

NOT USED PRV05 C035 PROVIDER SPECIALTY INFORMATION O 1

005010X223 • 837 • 2310A • PRV ASC X12N • INSURANCE SUBCOMMITTEEATTENDING PROVIDER SPECIALTY INFORMATION TECHNICAL REPORT • TYPE 3

322 MAY 2006

NOT USED PRV06 1223 Provider Organization Code O 1 ID 3/3

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310A • PRVTECHNICAL REPORT • TYPE 3 ATTENDING PROVIDER SPECIALTY INFORMATION

MAY 2006 323

REFREFERENCE INFORMATION 005010X223 • 837 • 2310A • REFATTENDING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

270 REF - ATTENDING PROVIDER SECONDARYIDENTIFICATION




Loop: 2310A — ATTENDING PROVIDER NAME

Segment Repeat: 4

Usage: SITUATIONAL

271 Situational Rule: Required prior to the mandated HIPAA National Provider Identifier (NPI)implementation date when an identification number other than the NPI isnecessary for the receiver to identify the provider.ORRequired on or after the mandated NPI Implementation Date when NM109in this loop is not used and an identification number other than the NPI isnecessary for the receiver to identify the provider.If not required by this implementation guide, do not send.

269 TR3 Example: REF✽ 1G✽ A12345~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

0B State License Number

1G Provider UPIN Number

1555 UPINs must be formatted as either X99999 orXXX999.



LU Location Number

005010X223 • 837 • 2310A • REF ASC X12N • INSURANCE SUBCOMMITTEEATTENDING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

324 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Attending Provider Secondary Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310A • REFTECHNICAL REPORT • TYPE 3 ATTENDING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 325

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310B • NM1OPERATING PHYSICIAN NAME

SEGMENT DETAIL

273 NM1 - OPERATING PHYSICIAN NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2310B — OPERATING PHYSICIAN NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

274 Situational Rule: Required when a surgical procedure code is listed on this claim. If notrequired by this implementation guide, do not send.

276 TR3 Notes: 1. The Operating Physician is the individual with primary responsibilityfor performing the surgical procedure(s).

277 2. Information in Loop ID-2310 applies to the entire claim unlessoverridden on a service line by the presence of Loop ID-2420 with thesame value in NM101.

275 TR3 Example: NM1✽ 72✽ 1✽ MEYERS✽ JANE✽✽✽✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2310B • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

326 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

72 Operating PhysicianREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Operating Physician Last Name



IMPLEMENTATION NAME: Operating Physician First Name



IMPLEMENTATION NAME: Operating Physician Middle Name or Initial




IMPLEMENTATION NAME: Operating Physician Name Suffix

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310B • NM1TECHNICAL REPORT • TYPE 3 OPERATING PHYSICIAN NAME

MAY 2006 327


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Operating Physician Primary Identifier




005010X223 • 837 • 2310B • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

328 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2310B • REFOPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

278 REF - OPERATING PHYSICIAN SECONDARYIDENTIFICATION




Loop: 2310B — OPERATING PHYSICIAN NAME

Segment Repeat: 4

Usage: SITUATIONAL



DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310B • REFTECHNICAL REPORT • TYPE 3 OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 329


SYNTAX: R0203

IMPLEMENTATION NAME: Operating Physician Secondary Identifier



005010X223 • 837 • 2310B • REF ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

330 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310C • NM1OTHER OPERATING PHYSICIAN NAME

SEGMENT DETAIL

279 NM1 - OTHER OPERATING PHYSICIAN NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2310C — OTHER OPERATING PHYSICIAN NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

280 Situational Rule: Required when another Operating Physician is involved. If not required bythe implementation guide, do not send.

282 TR3 Notes: 1. The Other Operating Physician is the individual performing asecondary surgical procedure or assisting the Operating Physician.

283 2. This Other Operating Physician segment can only be used whenOperating Physician information (Loop ID-2310B) is also sent on thisclaim.


281 TR3 Example: NM1✽ ZZ✽ 1✽ DOE✽ JOHN✽ A✽✽✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310C • NM1TECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN NAME

MAY 2006 331

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

ZZ Mutually Defined

284 ZZ is used to indicate Other Operating Physician.REQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Other Operating Physician Last Name



IMPLEMENTATION NAME: Other Operating Physician First Name



IMPLEMENTATION NAME: Other Operating Physician Middle Name or Initial




IMPLEMENTATION NAME: Other Operating Physician Name Suffix

005010X223 • 837 • 2310C • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER OPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

332 MAY 2006


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Other Operating Physician Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310C • NM1TECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN NAME

MAY 2006 333

REFREFERENCE INFORMATION 005010X223 • 837 • 2310C • REFOTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

285 REF - OTHER OPERATING PHYSICIANSECONDARY IDENTIFICATION




Loop: 2310C — OTHER OPERATING PHYSICIAN NAME

Segment Repeat: 4

Usage: SITUATIONAL



DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

005010X223 • 837 • 2310C • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

334 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Provider Secondary Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310C • REFTECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 335

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310D • NM1RENDERING PROVIDER NAME

SEGMENT DETAIL

689 NM1 - RENDERING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2310D — RENDERING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

288 Situational Rule: Required when the Rendering Provider is different than the AttendingProvider reported in Loop ID-2310A of this claim.ANDWhen state or federal regulatory requirements call for a “combinedclaim”, that is, a claim that includes both facility and professionalcomponents (for example, a Medicaid clinic bill or Critical AccessHospital Claim.)If not required by this implementation guide, do not send.

289 TR3 Notes: 1. The Rendering Provider is the health care professional who deliversor completes a particular medical service or non-surgical procedure.


692 TR3 Example: NM1✽ 82✽ 1✽ DOE✽ JANE✽ C✽✽✽ XX✽ 1234567804~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2310D • NM1 ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER NAME TECHNICAL REPORT • TYPE 3

336 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

82 Rendering ProviderREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Rendering Provider Last Name



IMPLEMENTATION NAME: Rendering Provider First Name



IMPLEMENTATION NAME: Rendering Provider Middle Name or Initial




IMPLEMENTATION NAME: Rendering Provider Name Suffix

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310D • NM1TECHNICAL REPORT • TYPE 3 RENDERING PROVIDER NAME

MAY 2006 337


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Rendering Provider Identifier




005010X223 • 837 • 2310D • NM1 ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER NAME TECHNICAL REPORT • TYPE 3

338 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2310D • REFRENDERING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

694 REF - RENDERING PROVIDER SECONDARYIDENTIFICATION




Loop: 2310D — RENDERING PROVIDER NAME

Segment Repeat: 4

Usage: SITUATIONAL



DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310D • REFTECHNICAL REPORT • TYPE 3 RENDERING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 339


SYNTAX: R0203

IMPLEMENTATION NAME: Rendering Provider Secondary Identifier



005010X223 • 837 • 2310D • REF ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

340 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310E • NM1SERVICE FACILITY LOCATION NAME

SEGMENT DETAIL

701 NM1 - SERVICE FACILITY LOCATION NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2310E — SERVICE FACILITY LOCATION NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

702 Situational Rule: Required when the location of health care service is different than thatcarried in Loop ID-2010AA (Billing Provider).If not required by this implementation guide, do not send.

703 TR3 Notes: 1. When an organization health care provider’s NPI is provided toidentify the Service Location, the organization health care providermust be external to the entity identified as the Billing Provider (forexample, reference lab). It is not permissible to report an organizationhealth care provider NPI as the Service Location if the entity beingidentified is a component (for example, subpart) of the BillingProvider. In that case, the subpart must be the Billing Provider.

700 TR3 Example: NM1✽ 77✽ 2✽ ABC CLINIC✽✽✽✽✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310E • NM1TECHNICAL REPORT • TYPE 3 SERVICE FACILITY LOCATION NAME

MAY 2006 341

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

77 Service LocationREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Laboratory or Facility Name






SYNTAX: P0809

705 SITUATIONAL RULE: Required when the service location to be identifiedhas an NPI and is not a component or subpart of the BillingProvider entity.If not required by this implementation guide, do not send.

CODE DEFINITION




SYNTAX: P0809

705 SITUATIONAL RULE: Required when the service location to be identifiedhas an NPI and is not a component or subpart of the BillingProvider entity.If not required by this implementation guide, do not send.

IMPLEMENTATION NAME: Laboratory or Facility Primary Identifier



005010X223 • 837 • 2310E • NM1 ASC X12N • INSURANCE SUBCOMMITTEESERVICE FACILITY LOCATION NAME TECHNICAL REPORT • TYPE 3

342 MAY 2006


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310E • NM1TECHNICAL REPORT • TYPE 3 SERVICE FACILITY LOCATION NAME

MAY 2006 343

N3PARTY LOCATION 005010X223 • 837 • 2310E • N3SERVICE FACILITY LOCATION ADDRESS

SEGMENT DETAIL

706 N3 - SERVICE FACILITY LOCATION ADDRESSX12 Segment Name: Party Location


Loop: 2310E — SERVICE FACILITY LOCATION NAME

Segment Repeat: 1

Usage: REQUIRED

707 TR3 Notes: 1. If service facility location is in an area where there are no streetaddresses, enter a description of where the service was rendered (forexample, “crossroad of State Road 34 and 45” or “Exit near Milemarker 265 on Interstate 80”.)


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Laboratory or Facility Address Line



IMPLEMENTATION NAME: Laboratory or Facility Address Line

005010X223 • 837 • 2310E • N3 ASC X12N • INSURANCE SUBCOMMITTEESERVICE FACILITY LOCATION ADDRESS TECHNICAL REPORT • TYPE 3

344 MAY 2006

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2310E • N4SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE

SEGMENT DETAIL

708 N4 - SERVICE FACILITY LOCATION CITY,STATE, ZIP CODE







Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Laboratory or Facility City Name

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310E • N4TECHNICAL REPORT • TYPE 3 SERVICE FACILITY LOCATION CITY, STATE, ZIP CODE

MAY 2006 345


SYNTAX: E0207



IMPLEMENTATION NAME: Laboratory or Facility State or Province Code




IMPLEMENTATION NAME: Laboratory or Facility Postal Zone or ZIP Code


1552 When reporting the ZIP code for U.S. addresses, the full nine digitZIP code must be provided.


SYNTAX: C0704











005010X223 • 837 • 2310E • N4 ASC X12N • INSURANCE SUBCOMMITTEESERVICE FACILITY LOCATION CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

346 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2310E • REFSERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

SEGMENT DETAIL

711 REF - SERVICE FACILITY LOCATIONSECONDARY IDENTIFICATION





Segment Repeat: 3

Usage: SITUATIONAL

1579 Situational Rule: Required prior to the mandated HIPAA National Provider Identifier (NPI)implementation date when an identification number other than the NPI isnecessary for the receiver to identify the provider.ORRequired on or after the mandated NPI implementation date when theentity is not a Health Care provider (a.k.a. an atypical provider), and anidentifier is necessary for the claims processor to identify the entity.If not required by this implementation guide, do not send.


DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




LU Location Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310E • REFTECHNICAL REPORT • TYPE 3 SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

MAY 2006 347


SYNTAX: R0203

IMPLEMENTATION NAME: Laboratory or Facility Secondary Identifier



005010X223 • 837 • 2310E • REF ASC X12N • INSURANCE SUBCOMMITTEESERVICE FACILITY LOCATION SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

348 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2310F • NM1REFERRING PROVIDER NAME

SEGMENT DETAIL

299 NM1 - REFERRING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2310F — REFERRING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 2

Usage: SITUATIONAL

301 Situational Rule: Required on an outpatient claim when the Referring Provider is differentthan the Attending Provider. If not required by this implementation guide,do not send.

302 TR3 Notes: 1. The Referring Provider is provider who sends the patient to anotherprovider for services.


300 TR3 Example: NM1✽ DN✽ 1✽ WELBY✽ MARCUS✽ W✽✽ JR✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310F • NM1TECHNICAL REPORT • TYPE 3 REFERRING PROVIDER NAME

MAY 2006 349

tdrinkard

Highlight

tdrinkard

Text Box

Change the Segment Repeat to 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

DN Referring ProviderREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Referring Provider Last Name



IMPLEMENTATION NAME: Referring Provider First Name



IMPLEMENTATION NAME: Referring Provider Middle Name or Initial




IMPLEMENTATION NAME: Referring Provider Name Suffix

005010X223 • 837 • 2310F • NM1 ASC X12N • INSURANCE SUBCOMMITTEEREFERRING PROVIDER NAME TECHNICAL REPORT • TYPE 3

350 MAY 2006


SYNTAX: P0809

303 SITUATIONAL RULE: Required for providers on or after the mandatedHIPAA National Provider Identifier (NPI) implementation date whenthe provider has received an NPI and the NPI is available to thesubmitter.ORRequired for providers prior to the mandated HIPAA NPIimplementation date when the provider has received an NPI and thesubmitter has the capability to send it.If not required by this implementation guide, do not send.

CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Referring Provider Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310F • NM1TECHNICAL REPORT • TYPE 3 REFERRING PROVIDER NAME

MAY 2006 351

REFREFERENCE INFORMATION 005010X223 • 837 • 2310F • REFREFERRING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

304 REF - REFERRING PROVIDER SECONDARYIDENTIFICATION




Loop: 2310F — REFERRING PROVIDER NAME

Segment Repeat: 3

Usage: SITUATIONAL


688 TR3 Notes: 1. The REF segment in Loop ID-2310 applies to the entire claim unlessoverridden on the service line level by the presence of a REF segmentwith the same value in REF01.


DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




005010X223 • 837 • 2310F • REF ASC X12N • INSURANCE SUBCOMMITTEEREFERRING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

352 MAY 2006




SYNTAX: R0203

IMPLEMENTATION NAME: Referring Provider Secondary Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2310F • REFTECHNICAL REPORT • TYPE 3 REFERRING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 353

SBRSUBSCRIBER INFORMATION 005010X223 • 837 • 2320 • SBROTHER SUBSCRIBER INFORMATION

SEGMENT DETAIL

306 SBR - OTHER SUBSCRIBER INFORMATIONX12 Segment Name: Subscriber Information

X12 Purpose: To record information specific to the primary insured and the insurance carrierfor that insured

X12 Set Notes: 1. Loop 2320 contains insurance information about: paying and otherInsurance Carriers for that Subscriber, Subscriber of the Other InsuranceCarriers, School or Employer Information for that Subscriber.

Loop: 2320 — OTHER SUBSCRIBER INFORMATION Loop Repeat: 10

Segment Repeat: 1

Usage: SITUATIONAL

308 Situational Rule: Required when other payers are known to potentially be involved inpaying on this claim. If not required by this implementation guide, do notsend.

309 TR3 Notes: 1. All information contained in Loop ID-2320 applies only to the payeridentified in Loop ID-2330B of this iteration of Loop ID-2320. It isspecific only to that payer. If information for an additional payer isnecessary, repeat Loop ID-2320 with its respective 2330 Loops.

310 2. See Crosswalking COB Data Elements section for more informationon handling COB in the 837.

307 TR3 Example: SBR✽ S✽ 01✽ GR00786✽✽✽✽✽✽ 13~

DIAGRAM

SBR01 1138 SBR02 1069 SBR03 127 SBR04 93 SBR05 1336 SBR06 1143

SBR ✽ Payer RespSeq No Code ✽ Individual

Relat Code ✽ ReferenceIdent ✽ Name ✽ Insurance

Type Code ✽ BenefitsCoord Code

M 1 ID 1/1 O 1 ID 2/2 O 1 AN 1/50 O 1 AN 1/60 O 1 ID 1/3 O 1 ID 1/1

SBR07 1073 SBR08 584 SBR09 1032

✽ Yes/No CondResp Code ✽ Employment

Status Code ✽ Claim FileInd Code ~

O 1 ID 1/1 O 1 ID 2/2 O 1 ID 1/2

005010X223 • 837 • 2320 • SBR ASC X12N • INSURANCE SUBCOMMITTEEOTHER SUBSCRIBER INFORMATION TECHNICAL REPORT • TYPE 3

354 MAY 2006

tdrinkard

Text Box

Remove the 2320 loop and all of the 2330x loops.

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED SBR01 1138 Payer Responsibility Sequence Number Code M 1 ID 1/1Code identifying the insurance carrier’s level of responsibility for a payment of aclaim

64 Within a given claim, the various values for the PayerResponsibility Sequence Number Code (other than value “U”) mayoccur no more than once.

CODE DEFINITION

A Payer Responsibility Four

B Payer Responsibility Five

C Payer Responsibility Six

D Payer Responsibility Seven

E Payer Responsibility Eight

F Payer Responsibility Nine

G Payer Responsibility Ten

H Payer Responsibility Eleven

P Primary

S Secondary

T Tertiary

U Unknown

65 This code may only be used in payer to payer COBclaims when the original payer determined thepresence of this coverage from eligibility filesreceived from this payer or when the original claimdid not provide the responsibility sequence for thispayer.

REQUIRED SBR02 1069 Individual Relationship Code O 1 ID 2/2Code indicating the relationship between two individuals or entities

SEMANTIC: SBR02 specifies the relationship to the person insured.

CODE DEFINITION

01 Spouse

18 Self

19 Child

20 Employee

21 Unknown

39 Organ Donor

40 Cadaver Donor

53 Life Partner

G8 Other Relationship

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • SBRTECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER INFORMATION

MAY 2006 355

SITUATIONAL SBR03 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: SBR03 is policy or group number.

1482 SITUATIONAL RULE: Required when the subscriber’s identification cardfor the non-destination payer identified in Loop ID-2330B of thisiteration of Loop ID-2320 shows a group number. If not required bythis implemetation guide, do not send.

IMPLEMENTATION NAME: Insured Group or Policy Number

312 This is not the number uniquely identifying the subscriber. Theunique subscriber number is submitted in Loop 2330A-NM109 forthis iteration of Loop ID-2320.

SITUATIONAL SBR04 93 Name O 1 AN 1/60Free-form name

SEMANTIC: SBR04 is plan name.

313 SITUATIONAL RULE: Required when SBR03 is not used and the groupname is available. If not required by this implementation guide, donot send.

IMPLEMENTATION NAME: Other Insured Group Name

NOT USED SBR05 1336 Insurance Type Code O 1 ID 1/3

NOT USED SBR06 1143 Coordination of Benefits Code O 1 ID 1/1

NOT USED SBR07 1073 Yes/No Condition or Response Code O 1 ID 1/1

NOT USED SBR08 584 Employment Status Code O 1 ID 2/2

SITUATIONAL SBR09 1032 Claim Filing Indicator Code O 1 ID 1/2Code identifying type of claim

314 SITUATIONAL RULE: Required prior to mandated use of the HIPAANational Plan ID. If not required by this implementation guide, donot send.

CODE DEFINITION

11 Other Non-Federal Programs

12 Preferred Provider Organization (PPO)

13 Point of Service (POS)

14 Exclusive Provider Organization (EPO)

15 Indemnity Insurance

16 Health Maintenance Organization (HMO) MedicareRisk

17 Dental Maintenance Organization

AM Automobile Medical

BL Blue Cross/Blue Shield

CH Champus

CI Commercial Insurance Co.

DS Disability

FI Federal Employees Program

HM Health Maintenance Organization

005010X223 • 837 • 2320 • SBR ASC X12N • INSURANCE SUBCOMMITTEEOTHER SUBSCRIBER INFORMATION TECHNICAL REPORT • TYPE 3

356 MAY 2006

LM Liability Medical

MA Medicare Part A

MB Medicare Part B

MC Medicaid

OF Other Federal Program

1484 Use code OF when submitting Medicare Part Dclaims.

TV Title V

VA Veterans Affairs Plan

WC Workers’ Compensation Health Claim

ZZ Mutually Defined

71 Use Code ZZ when Type of Insurance is not known.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • SBRTECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER INFORMATION

MAY 2006 357

CASCLAIMS ADJUSTMENT 005010X223 • 837 • 2320 • CASCLAIM LEVEL ADJUSTMENTS

SEGMENT DETAIL

738 CAS - CLAIM LEVEL ADJUSTMENTSX12 Segment Name: Claims Adjustment

X12 Purpose: To supply adjustment reason codes and amounts as needed for an entire claimor for a particular service within the claim being paid

X12 Syntax: 1. L050607If CAS05 is present, then at least one of CAS06 or CAS07 are required.

2. C0605If CAS06 is present, then CAS05 is required.


4. L080910If CAS08 is present, then at least one of CAS09 or CAS10 are required.












X12 Comments: 1. Adjustment information is intended to help the provider balance theremittance information. Adjustment amounts should fully explain thedifference between submitted charges and the amount paid.

Loop: 2320 — OTHER SUBSCRIBER INFORMATION

Segment Repeat: 5

Usage: SITUATIONAL

005010X223 • 837 • 2320 • CAS ASC X12N • INSURANCE SUBCOMMITTEECLAIM LEVEL ADJUSTMENTS TECHNICAL REPORT • TYPE 3

358 MAY 2006

739 Situational Rule: Required when the claim has been adjudicated by the payer identified inthis loop, and the claim has claim level adjustment information. If notrequired by this implementation guide, do not send.

740 TR3 Notes: 1. Submitters must use this CAS segment to report prior payers’ claimlevel adjustments that cause the amount paid to differ from theamount originally charged.

741 2. Only one Group Code is allowed per CAS. If it is necessary to sendmore than one Group Code at the claim level, repeat the CAS segment.

742 3. Codes and associated amounts must come from either paperremittance advice or 835s (Electronic Remittance Advice) received onthe claim. When the information originates from a paper remittanceadvice that does not use the standard Claim Adjustment ReasonCodes, the paper values must be converted to standard ClaimAdjustment Reason Codes.

743 4. A single CAS segment contains six repetitions of the “adjustmenttrio” composed of adjustment reason code, adjustment amount, andadjustment quantity. These six adjustment trios are used to report upto six adjustments related to a particular Claim Adjustment GroupCode (CAS01). The first non-zero adjustment is reported in the firstadjustment trio (CAS02-CAS04). If there is a second non-zeroadjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

736 TR3 Example: CAS✽ PR✽ 1✽ 7.93~

737 TR3 Example: CAS✽ OA✽ 93✽ 15.06~

DIAGRAM

CAS01 1033 CAS02 1034 CAS03 782 CAS04 380 CAS05 1034 CAS06 782

CAS ✽ Claim AdjGroup Code ✽ Claim Adj

Reason Code ✽ MonetaryAmount ✽ Quantity ✽ Claim Adj

Reason Code ✽ MonetaryAmount

M 1 ID 1/2 M 1 ID 1/5 M 1 R 1/18 O 1 R 1/15 X 1 ID 1/5 X 1 R 1/18


✽ Quantity ✽ Claim AdjReason Code ✽ Monetary

Amount ✽ Quantity ✽ Claim AdjReason Code ✽ Monetary

AmountX 1 R 1/15 X 1 ID 1/5 X 1 R 1/18 X 1 R 1/15 X 1 ID 1/5 X 1 R 1/18





CAS19 380

✽ Quantity~

X 1 R 1/15

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • CASTECHNICAL REPORT • TYPE 3 CLAIM LEVEL ADJUSTMENTS

MAY 2006 359

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CAS01 1033 Claim Adjustment Group Code M 1 ID 1/2Code identifying the general category of payment adjustment

CODE DEFINITION

CO Contractual Obligations

CR Correction and Reversals

OA Other adjustments

PI Payor Initiated Reductions

PR Patient ResponsibilityREQUIRED CAS02 1034 Claim Adjustment Reason Code M 1 ID 1/5

Code identifying the detailed reason the adjustment was made

IMPLEMENTATION NAME: Adjustment Reason Code

CODE SOURCE 139: Claim Adjustment Reason Code

109 See CODE SOURCE 139: Claim Adjustment Reason Code

REQUIRED CAS03 782 Monetary Amount M 1 R 1/18Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.

IMPLEMENTATION NAME: Adjustment Amount

SITUATIONAL CAS04 380 Quantity O 1 R 1/15Numeric value of quantity

SEMANTIC: CAS04 is the units of service being adjusted.

744 SITUATIONAL RULE: Required when the number of service units has beenadjusted. If not required by this implementation guide, do not send.

IMPLEMENTATION NAME: Adjustment Quantity

SITUATIONAL CAS05 1034 Claim Adjustment Reason Code X 1 ID 1/5Code identifying the detailed reason the adjustment was made

SYNTAX: L050607, C0605, C0705

745 SITUATIONAL RULE: Required when it is necessary to report an additionalnon-zero adjustment, beyond what has already been supplied, tothis claim for the Claim Adjustment Group Code reported in CAS01.If not required by this implementation guide, do not send.



SITUATIONAL CAS06 782 Monetary Amount X 1 R 1/18Monetary amount

SYNTAX: L050607, C0605

SEMANTIC: CAS06 is the amount of the adjustment.

746 SITUATIONAL RULE: Required when CAS05 is present. If not required bythis implementation guide, do not send.



360 MAY 2006

SITUATIONAL CAS07 380 Quantity X 1 R 1/15Numeric value of quantity

SYNTAX: L050607, C0705


747 SITUATIONAL RULE: Required when CAS05 is present and is related to aunits of service adjustment. If not required by this implementationguide, do not send.



SYNTAX: L080910, C0908, C1008





SYNTAX: L080910, C0908





SYNTAX: L080910, C1008





SYNTAX: L111213, C1211, C1311





MAY 2006 361


SYNTAX: L111213, C1211





SYNTAX: L111213, C1311





SYNTAX: L141516, C1514, C1614





SYNTAX: L141516, C1514





SYNTAX: L141516, C1614





362 MAY 2006


SYNTAX: L171819, C1817, C1917





SYNTAX: L171819, C1817





SYNTAX: L171819, C1917





MAY 2006 363

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2320 • AMTCOORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT

SEGMENT DETAIL

756 AMT - COORDINATION OF BENEFITS (COB)PAYER PAID AMOUNT

X12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

757 Situational Rule: Required when the claim has been adjudicated by the payer identified inLoop ID-2330B of this loop.ORRequired when Loop ID-2010AC is present. In this case, the claim is a postpayment recovery claim submitted by a subrogated Medicaid agency.If not required by this implementation guide, do not send.

317 TR3 Example: AMT✽ D✽ 411~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478



M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

D Payor Amount PaidREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Payer Paid Amount

758 It is acceptable to show “0” as the amount paid.

759 When Loop ID-2010AC is present, this is the amount the Medicaidagency actually paid.


005010X223 • 837 • 2320 • AMT ASC X12N • INSURANCE SUBCOMMITTEECOORDINATION OF BENEFITS (COB) PAYER PAID AMOUNT TECHNICAL REPORT • TYPE 3

364 MAY 2006

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2320 • AMTREMAINING PATIENT LIABILITY

SEGMENT DETAIL

765 AMT - REMAINING PATIENT LIABILITYX12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

767 Situational Rule: Required when the Other Payer identified in Loop ID-2330B (of thisiteration of Loop ID-2320) has adjudicated this claim and provided claimlevel information only.ORRequired when the Other Payer identified in Loop ID-2330B (of thisiteration of Loop ID-2320) has adjudicated this claim and the providerreceived a paper remittance advice and the provider does not have theability to report line item information.If not required by this implementation guide, do not send.

768 TR3 Notes: 1. In the judgment of the provider, this is the remaining amount to bepaid after adjudication by the Other Payer identified in Loop ID-2330Bof this iteration of Loop ID-2320.

769 2. This segment is only used in provider submitted claims. It is not usedin Payer-to-Payer Coordination of Benefits (COB).

770 3. This segment is not used if the line level (Loop ID-2430) RemainingPatient Liability AMT segment is used for this Other Payer.

766 TR3 Example: AMT✽ EAF✽ 75~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478

AMT ✽ Amount QualCode

✽ MonetaryAmount

✽ Cred/DebitFlag Code ~

M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

EAF Amount OwedREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Remaining Patient Liability


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • AMTTECHNICAL REPORT • TYPE 3 REMAINING PATIENT LIABILITY

MAY 2006 365

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2320 • AMTCOORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT

SEGMENT DETAIL

760 AMT - COORDINATION OF BENEFITS (COB)TOTAL NON-COVERED AMOUNT

X12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

762 Situational Rule: Required when the destination payer’s cost avoidance policy allowsproviders to bypass claim submission to the otherwise prior payeridentified in Loop ID-2330B. If not required by this implementation guide,do not send.

763 TR3 Notes: 1. When this segment is used, the amount reported in AMT02 must equalthe total claim charge amount reported in CLM02. Neither the priorpayer paid AMT, nor any CAS segments are used as this claim has notbeen adjudicated by this payer.

761 TR3 Example: AMT✽ A8✽ 273~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478



M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

A8 Noncovered Charges - ActualREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Non-Covered Charge Amount


005010X223 • 837 • 2320 • AMT ASC X12N • INSURANCE SUBCOMMITTEECOORDINATION OF BENEFITS (COB) TOTAL NON-COVERED AMOUNT TECHNICAL REPORT • TYPE 3

366 MAY 2006

OIOTHER HEALTH INSURANCE INFORMATION 005010X223 • 837 • 2320 • OIOTHER INSURANCE COVERAGE INFORMATION

SEGMENT DETAIL

778 OI - OTHER INSURANCE COVERAGEINFORMATION

X12 Segment Name: Other Health Insurance Information

X12 Purpose: To specify information associated with other health insurance coverage


Segment Repeat: 1

Usage: REQUIRED

779 TR3 Notes: 1. All information contained in the OI segment applies only to the payeridentified in Loop ID-2330B in this iteration of Loop ID-2320.

777 TR3 Example: OI✽✽✽ Y✽ B✽✽ Y~

DIAGRAM

OI01 1032 OI02 1383 OI03 1073 OI04 1351 OI05 1360 OI06 1363

OI ✽ Claim FileInd Code ✽ Claim Submt

Reason Code ✽ Yes/No CondResp Code ✽ Patient Sig

Source Code ✽ ProviderAgree Code ✽ Release of

Info Code ~

O 1 ID 1/2 O 1 ID 2/2 O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


NOT USED OI01 1032 Claim Filing Indicator Code O 1 ID 1/2

NOT USED OI02 1383 Claim Submission Reason Code O 1 ID 2/2

REQUIRED OI03 1073 Yes/No Condition or Response Code O 1 ID 1/1Code indicating a Yes or No condition or response

SEMANTIC: OI03 is the assignment of benefits indicator. A “Y” value indicatesinsured or authorized person authorizes benefits to be assigned to the provider;an “N” value indicates benefits have not been assigned to the provider.

IMPLEMENTATION NAME: Benefits Assignment Certification Indicator

780 This is a crosswalk from CLM08 when doing COB.

486 This element answers the question whether or not the insured hasauthorized the plan to remit payment directly to the provider.

CODE DEFINITION

N No

W Not Applicable

1563 Use code ‘W’ when the patient refuses to assignbenefits.

Y YesNOT USED OI04 1351 Patient Signature Source Code O 1 ID 1/1

NOT USED OI05 1360 Provider Agreement Code O 1 ID 1/1

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • OITECHNICAL REPORT • TYPE 3 OTHER INSURANCE COVERAGE INFORMATION

MAY 2006 367

REQUIRED OI06 1363 Release of Information Code O 1 ID 1/1Code indicating whether the provider has on file a signed statement by the patientauthorizing the release of medical data to other organizations

783 This is a crosswalk from CLM09 when doing COB.

487 The Release of Information response is limited to the informationcarried in this claim.

CODE DEFINITION

I Informed Consent to Release Medical Informationfor Conditions or Diagnoses Regulated by FederalStatutes

488 Required when the provider has not collected asignature AND state or federal laws do not require asignature be collected.

Y Yes, Provider has a Signed Statement PermittingRelease of Medical Billing Data Related to a Claim

489 Required when the provider has collected asignature.ORRequired when state or federal laws require asignature be collected.

005010X223 • 837 • 2320 • OI ASC X12N • INSURANCE SUBCOMMITTEEOTHER INSURANCE COVERAGE INFORMATION TECHNICAL REPORT • TYPE 3

368 MAY 2006

MIAMEDICARE INPATIENT ADJUDICATION 005010X223 • 837 • 2320 • MIAINPATIENT ADJUDICATION INFORMATION

SEGMENT DETAIL

1399 MIA - INPATIENT ADJUDICATIONINFORMATION

X12 Segment Name: Medicare Inpatient Adjudication

X12 Purpose: To provide claim-level data related to the adjudication of Medicare inpatientclaims


Segment Repeat: 1

Usage: SITUATIONAL

1398 Situational Rule: Required when inpatient adjudication information is reported in theremittance advice.ORRequired when it is necessary to report remark codes.If not required by this implementation guide, do not send.

1397 TR3 Example: MIA✽ 1✽✽✽ 3568.98✽ MA01✽✽✽✽✽✽✽✽✽✽✽✽✽✽✽ 21✽✽✽ MA25~

DIAGRAM

MIA01 380 MIA02 782 MIA03 380 MIA04 782 MIA05 127 MIA06 782

MIA ✽ Quantity ✽ MonetaryAmount ✽ Quantity ✽ Monetary

Amount ✽ ReferenceIdent ✽ Monetary

AmountM 1 R 1/15 O 1 R 1/18 O 1 R 1/15 O 1 R 1/18 O 1 AN 1/50 O 1 R 1/18


✽ MonetaryAmount ✽ Monetary

Amount ✽ MonetaryAmount ✽ Monetary

Amount ✽ MonetaryAmount ✽ Monetary

AmountO 1 R 1/18 O 1 R 1/18 O 1 R 1/18 O 1 R 1/18 O 1 R 1/18 O 1 R 1/18


✽ MonetaryAmount ✽ Monetary

Amount ✽ Quantity ✽ MonetaryAmount ✽ Monetary

Amount ✽ MonetaryAmount

O 1 R 1/18 O 1 R 1/18 O 1 R 1/15 O 1 R 1/18 O 1 R 1/18 O 1 R 1/18


✽ MonetaryAmount ✽ Reference

Ident ✽ ReferenceIdent ✽ Reference

Ident ✽ ReferenceIdent ✽ Monetary

Amount ~

O 1 R 1/18 O 1 AN 1/50 O 1 AN 1/50 O 1 AN 1/50 O 1 AN 1/50 O 1 R 1/18

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED MIA01 380 Quantity M 1 R 1/15Numeric value of quantity

SEMANTIC: MIA01 is the covered days.

IMPLEMENTATION NAME: Covered Days or Visits Count

NOT USED MIA02 782 Monetary Amount O 1 R 1/18

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • MIATECHNICAL REPORT • TYPE 3 INPATIENT ADJUDICATION INFORMATION

MAY 2006 369

SITUATIONAL MIA03 380 Quantity O 1 R 1/15Numeric value of quantity

SEMANTIC: MIA03 is the lifetime psychiatric days.

787 SITUATIONAL RULE: Required when returned in the remittance advice. Ifnot required by this implementation guide, do not send.

IMPLEMENTATION NAME: Lifetime Psychiatric Days Count

SITUATIONAL MIA04 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: MIA04 is the Diagnosis Related Group (DRG) amount.


IMPLEMENTATION NAME: Claim DRG Amount

SITUATIONAL MIA05 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: MIA05 is the Claim Payment Remark Code. See Code Source 411.


IMPLEMENTATION NAME: Claim Payment Remark Code


SEMANTIC: MIA06 is the disproportionate share amount.


IMPLEMENTATION NAME: Claim Disproportionate Share Amount


SEMANTIC: MIA07 is the Medicare Secondary Payer (MSP) pass-through amount.


IMPLEMENTATION NAME: Claim MSP Pass-through Amount


SEMANTIC: MIA08 is the total Prospective Payment System (PPS) capital amount.


IMPLEMENTATION NAME: Claim PPS Capital Amount

005010X223 • 837 • 2320 • MIA ASC X12N • INSURANCE SUBCOMMITTEEINPATIENT ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

370 MAY 2006


SEMANTIC: MIA09 is the Prospective Payment System (PPS) capital, federalspecific portion, Diagnosis Related Group (DRG) amount.


IMPLEMENTATION NAME: PPS-Capital FSP DRG Amount


SEMANTIC: MIA10 is the Prospective Payment System (PPS) capital, hospitalspecific portion, Diagnosis Related Group (DRG), amount.


IMPLEMENTATION NAME: PPS-Capital HSP DRG Amount


SEMANTIC: MIA11 is the Prospective Payment System (PPS) capital,disproportionate share, hospital Diagnosis Related Group (DRG) amount.


IMPLEMENTATION NAME: PPS-Capital DSH DRG Amount


SEMANTIC: MIA12 is the old capital amount.


IMPLEMENTATION NAME: Old Capital Amount


SEMANTIC: MIA13 is the Prospective Payment System (PPS) capital indirectmedical education claim amount.


IMPLEMENTATION NAME: PPS-Capital IME amount


SEMANTIC: MIA14 is hospital specific Diagnosis Related Group (DRG) Amount.


IMPLEMENTATION NAME: PPS-Operating Hospital Specific DRG Amount


MAY 2006 371

SITUATIONAL MIA15 380 Quantity O 1 R 1/15Numeric value of quantity

SEMANTIC: MIA15 is the cost report days.


IMPLEMENTATION NAME: Cost Report Day Count


SEMANTIC: MIA16 is the federal specific Diagnosis Related Group (DRG) amount.


IMPLEMENTATION NAME: PPS-Operating Federal Specific DRG Amount


SEMANTIC: MIA17 is the Prospective Payment System (PPS) Capital Outlieramount.


IMPLEMENTATION NAME: Claim PPS Capital Outlier Amount


SEMANTIC: MIA18 is the indirect teaching amount.


IMPLEMENTATION NAME: Claim Indirect Teaching Amount


SEMANTIC: MIA19 is the professional component amount billed but not payable.


IMPLEMENTATION NAME: Non-Payable Professional Component BilledAmount





005010X223 • 837 • 2320 • MIA ASC X12N • INSURANCE SUBCOMMITTEEINPATIENT ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

372 MAY 2006














SEMANTIC: MIA24 is the capital exception amount.


IMPLEMENTATION NAME: PPS-Capital Exception Amount


MAY 2006 373

MOAMEDICARE OUTPATIENT ADJUDICATION 005010X223 • 837 • 2320 • MOAOUTPATIENT ADJUDICATION INFORMATION

SEGMENT DETAIL

785 MOA - OUTPATIENT ADJUDICATIONINFORMATION

X12 Segment Name: Medicare Outpatient Adjudication

X12 Purpose: To convey claim-level data related to the adjudication of Medicare claims notrelated to an inpatient setting


Segment Repeat: 1

Usage: SITUATIONAL

786 Situational Rule: Required when outpatient adjudication information is reported in theremittance adviceORRequired when it is necessary to report remark codes.If not required by this implementation guide, do not send.

784 TR3 Example: MOA✽✽✽ A4~

DIAGRAM

MOA01 954 MOA02 782 MOA03 127 MOA04 127 MOA05 127 MOA06 127

MOA ✽ Percent ✽ MonetaryAmount ✽ Reference

Ident ✽ ReferenceIdent ✽ Reference

Ident ✽ ReferenceIdent

O 1 R 1/10 O 1 R 1/18 O 1 AN 1/50 O 1 AN 1/50 O 1 AN 1/50 O 1 AN 1/50

MOA07 127 MOA08 782 MOA09 782

✽ ReferenceIdent ✽ Monetary

Amount ✽ MonetaryAmount ~

O 1 AN 1/50 O 1 R 1/18 O 1 R 1/18

ELEMENT DETAIL

USAGEREF.DES.


SITUATIONAL MOA01 954 Percentage as Decimal O 1 R 1/10Percentage expressed as a decimal (e.g., 0.0 through 1.0 represents 0% through100%)

SEMANTIC: MOA01 is the reimbursement rate.


IMPLEMENTATION NAME: Reimbursement Rate

005010X223 • 837 • 2320 • MOA ASC X12N • INSURANCE SUBCOMMITTEEOUTPATIENT ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

374 MAY 2006

SITUATIONAL MOA02 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: MOA02 is the claim Health Care Financing Administration CommonProcedural Coding System (HCPCS) payable amount.


IMPLEMENTATION NAME: HCPCS Payable Amount

SITUATIONAL MOA03 127 Reference Identification O 1 AN 1/50Reference information as defined for a particular Transaction Set or as specifiedby the Reference Identification Qualifier

SEMANTIC: MOA03 is the Claim Payment Remark Code. See Code Source 411.



















ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2320 • MOATECHNICAL REPORT • TYPE 3 OUTPATIENT ADJUDICATION INFORMATION

MAY 2006 375


SEMANTIC: MOA08 is the End Stage Renal Disease (ESRD) payment amount.


IMPLEMENTATION NAME: End Stage Renal Disease Payment Amount


SEMANTIC: MOA09 is the professional component amount billed but not payable.


IMPLEMENTATION NAME: Non-Payable Professional Component BilledAmount

005010X223 • 837 • 2320 • MOA ASC X12N • INSURANCE SUBCOMMITTEEOUTPATIENT ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

376 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330A • NM1OTHER SUBSCRIBER NAME

SEGMENT DETAIL

322 NM1 - OTHER SUBSCRIBER NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Segments NM1-N4 contain name and address information of the insurancecarriers referenced in loop 2320.




Loop: 2330A — OTHER SUBSCRIBER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

323 TR3 Notes: 1. If the patient can be uniquely identified to the Other Payer indicatedin this iteration of Loop ID-2320 by a unique Member IdentificationNumber, then the patient is the subscriber or is considered to be thesubscriber and is identified in this Other Subscriber’s Name Loop ID-2330A.

324 2. If the patient is a dependent of the subscriber for this other coverageand cannot be uniquely identified to the Other Payer indicated in thisiteration of Loop ID-2320 by a unique Member Identification Number,then the subscriber for this other coverage is identified in this OtherSubscriber’s Name Loop ID-2330A.


78 TR3 Example: NM1✽ IL✽ 1✽ DOE✽ JOHN✽ T✽✽ JR✽ MI✽ 123456~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330A • NM1TECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER NAME

MAY 2006 377

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

IL Insured or SubscriberREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION

1 Person



SYNTAX: C1203

IMPLEMENTATION NAME: Other Insured Last Name



IMPLEMENTATION NAME: Other Insured First Name



IMPLEMENTATION NAME: Other Insured Middle Name



80 SITUATIONAL RULE: Required when NM102 = 1 (person) and the namesuffix of the person is needed to identify the individual. If notrequired by this implementation guide, do not send.

IMPLEMENTATION NAME: Other Insured Name Suffix

005010X223 • 837 • 2330A • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER SUBSCRIBER NAME TECHNICAL REPORT • TYPE 3

378 MAY 2006


SYNTAX: P0809

CODE DEFINITION

II Standard Unique Health Identifier for each Individualin the United States

1540 Required if the HIPAA Individual Patient Identifier ismandated use. If not required, use value ‘MI’instead.

MI Member Identification Number

82 The code MI is intended to be the subscriber’sidentification number as assigned by the payer. (Forexample, Insured’s ID, Subscriber’s ID, HealthInsurance Claim Number (HIC), etc.)

MI is also intended to be used in claims submitted tothe Indian Health Service/Contract Health Services(IHS/CHS) Fiscal Intermediary for the purpose ofreporting the Tribe Residency Code (Tribe CountyState). In the event that a Social Security Number(SSN) is also available on an IHS/CHS claim, put theSSN in REF02.

When sending the Social Security Number as theMember ID, it must be a string of exactly ninenumbers with no separators. For example, sending“111002222” would be valid, while sending “111-00-2222” would be invalid.


SYNTAX: P0809

IMPLEMENTATION NAME: Other Insured Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330A • NM1TECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER NAME

MAY 2006 379

N3PARTY LOCATION 005010X223 • 837 • 2330A • N3OTHER SUBSCRIBER ADDRESS

SEGMENT DETAIL

788 N3 - OTHER SUBSCRIBER ADDRESSX12 Segment Name: Party Location


Loop: 2330A — OTHER SUBSCRIBER NAME

Segment Repeat: 1

Usage: SITUATIONAL

789 Situational Rule: Required when the information is available. If not required by thisimplementation guide, do not send.


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Other Insured Address Line



IMPLEMENTATION NAME: Other Insured Address Line

005010X223 • 837 • 2330A • N3 ASC X12N • INSURANCE SUBCOMMITTEEOTHER SUBSCRIBER ADDRESS TECHNICAL REPORT • TYPE 3

380 MAY 2006

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2330A • N4OTHER SUBSCRIBER CITY, STATE, ZIP CODE

SEGMENT DETAIL

790 N4 - OTHER SUBSCRIBER CITY, STATE, ZIPCODE







Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Other Insured City Name

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330A • N4TECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER CITY, STATE, ZIP CODE

MAY 2006 381


SYNTAX: E0207



IMPLEMENTATION NAME: Other Insured State Code




IMPLEMENTATION NAME: Other Insured Postal Zone or ZIP Code



SYNTAX: C0704











005010X223 • 837 • 2330A • N4 ASC X12N • INSURANCE SUBCOMMITTEEOTHER SUBSCRIBER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

382 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2330A • REFOTHER SUBSCRIBER SECONDARY IDENTIFICATION

SEGMENT DETAIL

325 REF - OTHER SUBSCRIBER SECONDARYIDENTIFICATION





Segment Repeat: 2

Usage: SITUATIONAL

326 Situational Rule: Required when an additional identification number to that provided inNM109 of this loop is necessary for the claim processor to identify theentity. If not required by this implementation guide, do not send.

101 TR3 Example: REF✽ SY✽ 123456789~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

SY Social Security Number

327 The Social Security Number must be a string ofexactly nine numbers with no separators. Forexample, sending “111002222” would be valid, whilesending “111-00-2222” would be invalid.


SYNTAX: R0203

IMPLEMENTATION NAME: Other Insured Additional Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330A • REFTECHNICAL REPORT • TYPE 3 OTHER SUBSCRIBER SECONDARY IDENTIFICATION

MAY 2006 383

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330B • NM1OTHER PAYER NAME

SEGMENT DETAIL

328 NM1 - OTHER PAYER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2330B — OTHER PAYER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: REQUIRED

310 TR3 Notes: 1. See Crosswalking COB Data Elements section for more informationon handling COB in the 837.

104 TR3 Example: NM1✽ PR✽ 2✽ ABC INSURANCE CO✽✽✽✽✽ PI✽ 11122333~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

PR PayerREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION

2 Non-Person Entity

005010X223 • 837 • 2330B • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER NAME TECHNICAL REPORT • TYPE 3

384 MAY 2006


SYNTAX: C1203

IMPLEMENTATION NAME: Other Payer Last or Organization Name






SYNTAX: P0809





CODE DEFINITION





SYNTAX: P0809

IMPLEMENTATION NAME: Other Payer Primary Identifier

330 When sending Line Adjudication Information for this payer, theidentifier sent in SVD01 (Payer Identifier) of Loop ID-2430 (LineAdjudication Information) must match this value.




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER NAME

MAY 2006 385

N3PARTY LOCATION 005010X223 • 837 • 2330B • N3OTHER PAYER ADDRESS

SEGMENT DETAIL

791 N3 - OTHER PAYER ADDRESSX12 Segment Name: Party Location


Loop: 2330B — OTHER PAYER NAME

Segment Repeat: 1

Usage: SITUATIONAL

792 Situational Rule: Required when the payer address is available and the submitter intendsfor the claim to be printed on paper at the next EDI location (for example, aclearinghouse). If not required by this implementation guide, do not send.


DIAGRAM

N301 166 N302 166


Information ~

M 1 AN 1/55 O 1 AN 1/55

ELEMENT DETAIL

USAGEREF.DES.



IMPLEMENTATION NAME: Other Payer Address Line



IMPLEMENTATION NAME: Other Payer Address Line

005010X223 • 837 • 2330B • N3 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER ADDRESS TECHNICAL REPORT • TYPE 3

386 MAY 2006

N4GEOGRAPHIC LOCATION 005010X223 • 837 • 2330B • N4OTHER PAYER CITY, STATE, ZIP CODE

SEGMENT DETAIL

793 N4 - OTHER PAYER CITY, STATE, ZIP CODEX12 Segment Name: Geographic Location






Segment Repeat: 1

Usage: REQUIRED


DIAGRAM

N401 19 N402 156 N403 116 N404 26 N405 309 N406 310





N407 1715


X 1 ID 1/3

ELEMENT DETAIL

USAGEREF.DES.




IMPLEMENTATION NAME: Other Payer City Name


SYNTAX: E0207



IMPLEMENTATION NAME: Other Payer State Code


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • N4TECHNICAL REPORT • TYPE 3 OTHER PAYER CITY, STATE, ZIP CODE

MAY 2006 387



IMPLEMENTATION NAME: Other Payer Postal Zone or ZIP Code



SYNTAX: C0704











005010X223 • 837 • 2330B • N4 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER CITY, STATE, ZIP CODE TECHNICAL REPORT • TYPE 3

388 MAY 2006

DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2330B • DTPCLAIM CHECK OR REMITTANCE DATE

SEGMENT DETAIL

798 DTP - CLAIM CHECK OR REMITTANCE DATEX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: SITUATIONAL

800 Situational Rule: Required when the payer identified in this loop has previouslyadjudicated the claim and Loop ID-2430, Line Check or Remittance Date,is not used. If not required by this implementation guide, do not send.

799 TR3 Example: DTP✽ 573✽ D8✽ 20040203~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

573 Date Claim PaidREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



CODE DEFINITION



IMPLEMENTATION NAME: Adjudication or Payment Date

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • DTPTECHNICAL REPORT • TYPE 3 CLAIM CHECK OR REMITTANCE DATE

MAY 2006 389

REFREFERENCE INFORMATION 005010X223 • 837 • 2330B • REFOTHER PAYER SECONDARY IDENTIFIER

SEGMENT DETAIL

332 REF - OTHER PAYER SECONDARYIDENTIFIER





Segment Repeat: 2

Usage: SITUATIONAL


435 TR3 Example: REF✽ 2U✽ 98765~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION








005010X223 • 837 • 2330B • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER SECONDARY IDENTIFIER TECHNICAL REPORT • TYPE 3

390 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Secondary Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER SECONDARY IDENTIFIER

MAY 2006 391

REFREFERENCE INFORMATION 005010X223 • 837 • 2330B • REFOTHER PAYER PRIOR AUTHORIZATION NUMBER

SEGMENT DETAIL

1538 REF - OTHER PAYER PRIORAUTHORIZATION NUMBER





Segment Repeat: 1

Usage: SITUATIONAL

1564 Situational Rule: Required when the payer identified in this loop has assigned a priorauthorization number to this claim.If not required by this implementation guide, do not send.

803 TR3 Example: REF✽ G1✽ AB333-Y5~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

G1 Prior Authorization NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Prior Authorization Number



005010X223 • 837 • 2330B • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER PRIOR AUTHORIZATION NUMBER TECHNICAL REPORT • TYPE 3

392 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2330B • REFOTHER PAYER REFERRAL NUMBER

SEGMENT DETAIL

1539 REF - OTHER PAYER REFERRAL NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

804 Situational Rule: Required when the payer identified in this loop has assigned a referralnumber to this claim.If not required by this implementation guide, do not send.

948 TR3 Example: REF✽ 9F✽ 12345~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9F Referral NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Prior Authorization or ReferralNumber



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER REFERRAL NUMBER

MAY 2006 393

REFREFERENCE INFORMATION 005010X223 • 837 • 2330B • REFOTHER PAYER CLAIM ADJUSTMENT INDICATOR

SEGMENT DETAIL

805 REF - OTHER PAYER CLAIM ADJUSTMENTINDICATOR





Segment Repeat: 1

Usage: SITUATIONAL

807 Situational Rule: Required when the claim is being sent in the payer-to-payer COB model, ANDthe destination payer is secondary to the payer identified in this Loop ID-2330B, ANDthe payer identified in this Loop ID-2330B has re-adjudicated the claim.If not required by this implementation guide, do not send.

1409 TR3 Example: REF✽ T4✽ Y~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

T4 Signal CodeREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Claim Adjustment Indicator

1411 Only allowed value is “Y”.



005010X223 • 837 • 2330B • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER CLAIM ADJUSTMENT INDICATOR TECHNICAL REPORT • TYPE 3

394 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2330B • REFOTHER PAYER CLAIM CONTROL NUMBER

SEGMENT DETAIL

1580 REF - OTHER PAYER CLAIM CONTROLNUMBER





Segment Repeat: 1

Usage: SITUATIONAL

1581 Situational Rule: Required when it is necessary to identify the Other Payer’s Claim ControlNumber in a payer-to-payer COB situation.ORRequired when the Other Payer’s Claim Control Number is available.If not required by this implementation guide, do not send.

579 TR3 Example: REF✽ F8✽ R555588~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

F8 Original Reference Number

334 This is the payer’s internal Claim Control Numberfor this claim for the payer identified in this iterationof Loop ID-2330. This value is typically used inpayer-to-payer COB situations only.


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer’s Claim Control Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330B • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER CLAIM CONTROL NUMBER

MAY 2006 395

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330C • NM1OTHER PAYER ATTENDING PROVIDER

SEGMENT DETAIL

1412 NM1 - OTHER PAYER ATTENDING PROVIDERX12 Segment Name: Individual or Organizational Name






Loop: 2330C — OTHER PAYER ATTENDING PROVIDER Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

815 Situational Rule: Required prior to the mandated implementation of the HIPAA NationalProvider Identifier (NPI) rule when the provider in the corresponding LoopID-2310 is sent and one or more additional payer-specific provideridentification numbers are required by this non-destination payer (Loop ID-2330B) to identify the provider.ORRequired after the mandated implementation of the NPI rule for providerswho are not Health Care Providers when the provider is sent in thecorresponding Loop ID-2310 and one or more additional payer-specificprovider identification numbers are required by this non-destination payer(Loop ID-2330B) to identify the provider.If not required by this implementation guide, do not send.


1413 TR3 Example: NM1✽ 71✽ 1~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330C • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER ATTENDING PROVIDER TECHNICAL REPORT • TYPE 3

396 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

71 Attending PhysicianREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION

1 PersonNOT USED NM103 1035 Name Last or Organization Name X 1 AN 1/60










ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330C • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER ATTENDING PROVIDER

MAY 2006 397

REFREFERENCE INFORMATION 005010X223 • 837 • 2330C • REFOTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

1414 REF - OTHER PAYER ATTENDING PROVIDERSECONDARY IDENTIFICATION




Loop: 2330C — OTHER PAYER ATTENDING PROVIDER

Segment Repeat: 4

Usage: REQUIRED

817 TR3 Notes: 1. Non-destination (COB) payer’s provider identification number(s).



DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION





818 This code designates a proprietary provider numberfor the non-destination payer identified in the OtherPayer Name Loop ID-2330B for this iteration of LoopID-2320. This is true regardless of whether thatpayer is Medicare, Medicaid, a Blue Cross BlueShield plan, a commercial plan, or any other healthplan.

LU Location Number

005010X223 • 837 • 2330C • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

398 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Attending Provider SecondaryIdentifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330C • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 399

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330D • NM1OTHER PAYER OPERATING PHYSICIAN

SEGMENT DETAIL

1416 NM1 - OTHER PAYER OPERATING PHYSICIANX12 Segment Name: Individual or Organizational Name






Loop: 2330D — OTHER PAYER OPERATING PHYSICIAN Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL



1415 TR3 Example: NM1✽ 72✽ 1~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330D • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER OPERATING PHYSICIAN TECHNICAL REPORT • TYPE 3

400 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330D • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER OPERATING PHYSICIAN

MAY 2006 401

REFREFERENCE INFORMATION 005010X223 • 837 • 2330D • REFOTHER PAYER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

1417 REF - OTHER PAYER OPERATINGPHYSICIAN SECONDARY IDENTIFICATION




Loop: 2330D — OTHER PAYER OPERATING PHYSICIAN

Segment Repeat: 4

Usage: REQUIRED




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

005010X223 • 837 • 2330D • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER OPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

402 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Operating Provider SecondaryIdentifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330D • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 403

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330E • NM1OTHER PAYER OTHER OPERATING PHYSICIAN

SEGMENT DETAIL

1418 NM1 - OTHER PAYER OTHER OPERATINGPHYSICIAN

X12 Segment Name: Individual or Organizational Name






Loop: 2330E — OTHER PAYER OTHER OPERATING PHYSICIAN LoopRepeat: 1

Segment Repeat: 1

Usage: SITUATIONAL



1419 TR3 Example: NM1✽ ZZ✽ 1~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038




✽ NameFirst

✽ NameMiddle

✽ NamePrefix


NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330E • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER OTHER OPERATING PHYSICIAN TECHNICAL REPORT • TYPE 3

404 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

ZZ Mutually Defined




CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330E • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER OTHER OPERATING PHYSICIAN

MAY 2006 405

REFREFERENCE INFORMATION 005010X223 • 837 • 2330E • REFOTHER PAYER OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

1420 REF - OTHER PAYER OTHER OPERATINGPHYSICIAN SECONDARY IDENTIFICATION




Loop: 2330E — OTHER PAYER OTHER OPERATING PHYSICIAN

Segment Repeat: 4

Usage: REQUIRED




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

005010X223 • 837 • 2330E • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

406 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Other Operating PhysicianSecondary Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330E • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 407

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330F • NM1OTHER PAYER SERVICE FACILITY LOCATION

SEGMENT DETAIL

825 NM1 - OTHER PAYER SERVICE FACILITYLOCATION







Loop: 2330F — OTHER PAYER SERVICE FACILITY LOCATION Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL



826 TR3 Example: NM1✽ 77✽ 2~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330F • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER SERVICE FACILITY LOCATION TECHNICAL REPORT • TYPE 3

408 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

77 Service LocationREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330F • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER SERVICE FACILITY LOCATION

MAY 2006 409

REFREFERENCE INFORMATION 005010X223 • 837 • 2330F • REFOTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

SEGMENT DETAIL

827 REF - OTHER PAYER SERVICE FACILITYLOCATION SECONDARY IDENTIFICATION




Loop: 2330F — OTHER PAYER SERVICE FACILITY LOCATION

Segment Repeat: 3

Usage: REQUIRED




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Service Facility Location Identifier

005010X223 • 837 • 2330F • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

410 MAY 2006



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330F • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER SERVICE FACILITY LOCATION SECONDARY IDENTIFICATION

MAY 2006 411

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330G • NM1OTHER PAYER RENDERING PROVIDER NAME

SEGMENT DETAIL

1422 NM1 - OTHER PAYER RENDERINGPROVIDER NAME







Loop: 2330G — OTHER PAYER RENDERING PROVIDER NAME Loop Repeat:1

Segment Repeat: 1

Usage: SITUATIONAL



1425 TR3 Example: NM1✽ 82✽ 1~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038




✽ NameFirst

✽ NameMiddle

✽ NamePrefix


NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330G • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER RENDERING PROVIDER NAME TECHNICAL REPORT • TYPE 3

412 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330G • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER RENDERING PROVIDER NAME

MAY 2006 413

REFREFERENCE INFORMATION 005010X223 • 837 • 2330G • REFOTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

821 REF - OTHER PAYER RENDERING PROVIDERSECONDARY IDENTIFICATION




Loop: 2330G — OTHER PAYER RENDERING PROVIDER NAME

Segment Repeat: 4

Usage: REQUIRED




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






LU Location Number

005010X223 • 837 • 2330G • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

414 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Rendering Provider SecondaryIdentifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330G • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 415

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330H • NM1OTHER PAYER REFERRING PROVIDER

SEGMENT DETAIL

813 NM1 - OTHER PAYER REFERRING PROVIDERX12 Segment Name: Individual or Organizational Name






Loop: 2330H — OTHER PAYER REFERRING PROVIDER Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL



1431 TR3 Example: NM1✽ DN✽ 1~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330H • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER REFERRING PROVIDER TECHNICAL REPORT • TYPE 3

416 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330H • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER REFERRING PROVIDER

MAY 2006 417

REFREFERENCE INFORMATION 005010X223 • 837 • 2330H • REFOTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

1432 REF - OTHER PAYER REFERRING PROVIDERSECONDARY IDENTIFICATION




Loop: 2330H — OTHER PAYER REFERRING PROVIDER

Segment Repeat: 3

Usage: REQUIRED




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION






005010X223 • 837 • 2330H • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

418 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Referring Provider Identifier



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330H • REFTECHNICAL REPORT • TYPE 3 OTHER PAYER REFERRING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 419

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2330I • NM1OTHER PAYER BILLING PROVIDER

SEGMENT DETAIL

831 NM1 - OTHER PAYER BILLING PROVIDERX12 Segment Name: Individual or Organizational Name






Loop: 2330I — OTHER PAYER BILLING PROVIDER Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL



832 TR3 Example: NM1✽ 85✽ 2~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2330I • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER BILLING PROVIDER TECHNICAL REPORT • TYPE 3

420 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

85 Billing ProviderREQUIRED NM102 1065 Entity Type Qualifier M 1 ID 1/1



CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2330I • NM1TECHNICAL REPORT • TYPE 3 OTHER PAYER BILLING PROVIDER

MAY 2006 421

REFREFERENCE INFORMATION 005010X223 • 837 • 2330I • REFOTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

834 REF - OTHER PAYER BILLING PROVIDERSECONDARY IDENTIFICATION




Loop: 2330I — OTHER PAYER BILLING PROVIDER

Segment Repeat: 2

Usage: REQUIRED



DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION





SYNTAX: R0203

IMPLEMENTATION NAME: Other Payer Billing Provider Identifier



005010X223 • 837 • 2330I • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER PAYER BILLING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

422 MAY 2006

LXTRANSACTION SET LINE NUMBER 005010X223 • 837 • 2400 • LXSERVICE LINE NUMBER

SEGMENT DETAIL

341 LX - SERVICE LINE NUMBERX12 Segment Name: Transaction Set Line Number

X12 Purpose: To reference a line number in a transaction set

X12 Set Notes: 1. Loop 2400 contains Service Line information.

Loop: 2400 — SERVICE LINE NUMBER Loop Repeat: 999

Segment Repeat: 1

Usage: REQUIRED

342 TR3 Notes: 1. The LX functions as a line counter.

343 2. The Service Line LX segment must begin with one and is incrementedby one for each additional service line of a claim.

344 3. LX01 is used to indicate bundling in SVD06 in the Line ItemAdjudication loop. See Section 1.4.1.2 for more information onbundling and unbundling.

340 TR3 Example: LX✽ 1~

DIAGRAM

LX01 554

LX ✽ AssignedNumber

M 1 N0 1/6

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED LX01 554 Assigned Number M 1 N0 1/6Number assigned for differentiation within a transaction set

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • LXTECHNICAL REPORT • TYPE 3 SERVICE LINE NUMBER

MAY 2006 423

SV2INSTITUTIONAL SERVICE 005010X223 • 837 • 2400 • SV2INSTITUTIONAL SERVICE LINE

SEGMENT DETAIL

346 SV2 - INSTITUTIONAL SERVICE LINEX12 Segment Name: Institutional Service

X12 Purpose: To specify the service line item detail for a health care institution

X12 Syntax: 1. R0102At least one of SV201 or SV202 is required.

2. P0405If either SV204 or SV205 is present, then the other is required.

Loop: 2400 — SERVICE LINE NUMBER

Segment Repeat: 1

Usage: REQUIRED

345 TR3 Example: SV2✽ 0300✽ HC:81099✽ 73.42✽ UN✽ 1~

347 TR3 Example: SV2✽ 0120✽✽ 1500✽ DA✽ 5~

DIAGRAM

SV201 234 SV202 C003 SV203 782 SV204 355 SV205 380 SV206 1371

SV2 ✽ Product/Service ID ✽ Comp. Med.

Proced. ID ✽ MonetaryAmount ✽ Unit/Basis

Meas Code ✽ Quantity ✽ UnitRate

X 1 AN 1/48 X 1 O 1 R 1/18 X 1 ID 2/2 X 1 R 1/15 O 1 R 1/10

SV207 782 SV208 1073 SV209 1345 SV210 1337

✽ MonetaryAmount ✽ Yes/No Cond

Resp Code ✽ Nurse HomeStatus Code ✽ Level of

Care Code ~

O 1 R 1/18 O 1 ID 1/1 O 1 ID 1/1 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED SV201 234 Product/Service ID X 1 AN 1/48Identifying number for a product or service

SYNTAX: R0102

SEMANTIC: SV201 is the revenue code.

IMPLEMENTATION NAME: Service Line Revenue Code

349 See Code Source 132: National Uniform Billing Committee (NUBC)Codes.

005010X223 • 837 • 2400 • SV2 ASC X12N • INSURANCE SUBCOMMITTEEINSTITUTIONAL SERVICE LINE TECHNICAL REPORT • TYPE 3

424 MAY 2006

SITUATIONAL SV202 C003 COMPOSITE MEDICAL PROCEDUREIDENTIFIER

X 1

To identify a medical procedure by its standardized codes and applicablemodifiers

350 SITUATIONAL RULE: Required for outpatient claims when an appropriateHCPCS or HIPPS code exists for this service line item.ORRequired for inpatient claims when an appropriate HCPCS (drugsand/or biologics only) or HIPPS code exists for this service lineitem.If not required by this implementation guide, do not send.

REQUIRED SV202 - 1 235 Product/Service ID Qualifier M ID 2/2Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

SEMANTIC:



CODE DEFINITION

ER Jurisdiction Specific Procedure and Supply Codes

1529 This code set is not allowed for use under HIPAA atthe time of this writing. The qualifier can only beused:If a new rule names the Jurisdiction SpecificProcedure and Supply Codes as an allowable codeset under HIPAA, ORThe Secretary grants an exception to use the codeset as a pilot project as allowed under the law, ORFor claims which are not covered under HIPAA.

CODE SOURCE 576: Workers Compensation Specific Procedureand Supply Codes

HC Health Care Financing Administration CommonProcedural Coding System (HCPCS) Codes

351 Because the AMA’s CPT codes are also level 1HCPCS codes, they are reported under HC.

CODE SOURCE 130: Healthcare Common Procedural CodingSystem

HP Health Insurance Prospective Payment System(HIPPS) Skilled Nursing Facility Rate Code

CODE SOURCE 716: Health Insurance Prospective PaymentSystem (HIPPS) Rate Code for Skilled Nursing Facilities

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • SV2TECHNICAL REPORT • TYPE 3 INSTITUTIONAL SERVICE LINE

MAY 2006 425

IV Home Infusion EDI Coalition (HIEC) Product/ServiceCode

352 This code set is not allowed for use under HIPAA atthe time of this writing. The qualifier can only beused: If a new rule names the Home Infusion EDI Coalition(HIEC) Product/Service Codes as an allowable codeset under HIPAA, OR The Secretary grants an exception to use the codeset as a pilot project as allowed under the law, OR For claims which are not covered under HIPAA.

CODE SOURCE 513: Home Infusion EDI Coalition (HIEC)Product/Service Code List

WK Advanced Billing Concepts (ABC) Codes

353 At the time of this writing, this code set has beenapproved by the Secretary of HHS as a pilot projectallowed under HIPAA law. The qualifier may only be used in transactionscovered under HIPAA; By parties registered in the pilot project and theirtrading partners, ORIf a new rule names the Complementary, Alternative,or Holistic Procedure Codes as an allowable codeset under HIPAA, ORFor claims which are not covered under HIPAA.

CODE SOURCE 843: Advanced Billing Concepts (ABC) CodesREQUIRED SV202 - 2 234 Product/Service ID M AN 1/48


SEMANTIC:

If C003-08 is used, then C003-02 represents the beginning value in therange in which the code occurs.


SITUATIONAL SV202 - 3 1339 Procedure Modifier O AN 2/2This identifies special circumstances related to the performance of theservice, as defined by trading partners

SEMANTIC:

C003-03 modifies the value in C003-02 and C003-08.

355 SITUATIONAL RULE: Required when a modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. This is the first procedure code modifier. Ifnot required by this implementation guide, do not send.


SEMANTIC:


356 SITUATIONAL RULE: Required when a second modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.


426 MAY 2006


SEMANTIC:


357 SITUATIONAL RULE: Required when a third modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.


SEMANTIC:


358 SITUATIONAL RULE: Required when a fourth modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.

SITUATIONAL SV202 - 7 352 Description O AN 1/80A free-form description to clarify the related data elements and theircontent

SEMANTIC:

C003-07 is the description of the procedure identified in C003-02.

1511 SITUATIONAL RULE: Required when, in the judgment of thesubmitter, the Procedure Code does not definitivelydescribe the service/product/supply and Loop ID-2410 isnot used.ORRequired when SV202-2 is a non-specific Procedure Code.Non-specific codes may include in their descriptors termssuch as: Not Otherwise Classified (NOC); Unlisted;Unspecified; Unclassified; Other; Miscellaneous;Prescription Drug, Generic; or Prescription Drug, BrandName.If not required by this implementation guide, do not send.

NOT USED SV202 - 8 234 Product/Service ID O AN 1/48

REQUIRED SV203 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: SV203 is the submitted service line item amount.

IMPLEMENTATION NAME: Line Item Charge Amount

359 This is the total charge amount for this service line. The amount isinclusive of the provider’s base charge and any applicable taxamounts reported within this line’s AMT segments.

843 Zero “0” is an acceptable value for this element.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • SV2TECHNICAL REPORT • TYPE 3 INSTITUTIONAL SERVICE LINE

MAY 2006 427

REQUIRED SV204 355 Unit or Basis for Measurement Code X 1 ID 2/2Code specifying the units in which a value is being expressed, or manner in whicha measurement has been taken

SYNTAX: P0405

CODE DEFINITION

DA Days

UN UnitREQUIRED SV205 380 Quantity X 1 R 1/15


SYNTAX: P0405

IMPLEMENTATION NAME: Service Unit Count


NOT USED SV206 1371 Unit Rate O 1 R 1/10

SITUATIONAL SV207 782 Monetary Amount O 1 R 1/18Monetary amount

SEMANTIC: SV207 is a non-covered service amount.

361 SITUATIONAL RULE: Required if needed to report line specific non-covered charge amount. If not required this implementation guide,do not send.

IMPLEMENTATION NAME: Line Item Denied Charge or Non-Covered ChargeAmount

NOT USED SV208 1073 Yes/No Condition or Response Code O 1 ID 1/1

NOT USED SV209 1345 Nursing Home Residential Status Code O 1 ID 1/1

NOT USED SV210 1337 Level of Care Code O 1 ID 1/1


428 MAY 2006

PWKPAPERWORK 005010X223 • 837 • 2400 • PWKLINE SUPPLEMENTAL INFORMATION

SEGMENT DETAIL

1587 PWK - LINE SUPPLEMENTAL INFORMATIONX12 Segment Name: Paperwork

X12 Purpose: To identify the type or transmission or both of paperwork or supportinginformation

X12 Syntax: 1. P0506If either PWK05 or PWK06 is present, then the other is required.


Segment Repeat: 10

Usage: SITUATIONAL

176 Situational Rule: Required when there is a paper attachment following this claim.ORRequired when attachments are sent electronically (PWK02 = EL) but aretransmitted in another functional group (for example, 275) rather than bypaper. PWK06 is then used to identify the attached electronicdocumentation. The number in PWK06 is carried in the TRN of theelectronic attachment.ORRequired when the provider deems it necessary to identify additionalinformation that is being held at the provider’s office and is available uponrequest by the payer (or appropriate entity), but the information is notbeing submitted with the claim. Use the value of “AA” in PWK02 to conveythis specific use of the PWK segment.If not required by this implementation guide, do not send.

177 TR3 Example: PWK✽ OZ✽ BM✽✽✽ AC✽ DMN0012~

DIAGRAM

PWK01 755 PWK02 756 PWK03 757 PWK04 98 PWK05 66 PWK06 67

PWK ✽ Report TypeCode ✽ Report

Transm Code ✽ ReportCopies Need ✽ Entity ID

Code ✽ ID CodeQualifier ✽ ID

CodeM 1 ID 2/2 O 1 ID 1/2 O 1 N0 1/2 O 1 ID 2/3 X 1 ID 1/2 X 1 AN 2/80

PWK07 352 PWK08 C002 PWK09 1525

✽ Description ✽ ActionsIndicated ✽ Request

Categ Code ~

O 1 AN 1/80 O 1 O 1 ID 1/2

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • PWKTECHNICAL REPORT • TYPE 3 LINE SUPPLEMENTAL INFORMATION

MAY 2006 429

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED PWK01 755 Report Type Code M 1 ID 2/2Code indicating the title or contents of a document, report or supporting item

IMPLEMENTATION NAME: Attachment Report Type Code

CODE DEFINITION

03 Report Justifying Treatment Beyond UtilizationGuidelines

04 Drugs Administered

05 Treatment Diagnosis

06 Initial Assessment

07 Functional Goals

08 Plan of Treatment

09 Progress Report

10 Continued Treatment

11 Chemical Analysis

13 Certified Test Report

15 Justification for Admission

21 Recovery Plan

A3 Allergies/Sensitivities Document

A4 Autopsy Report

AM Ambulance Certification

AS Admission Summary

B2 Prescription

B3 Physician Order

B4 Referral Form

BR Benchmark Testing Results

BS Baseline

BT Blanket Test Results

CB Chiropractic Justification

CK Consent Form(s)

CT Certification

D2 Drug Profile Document

DA Dental Models

DB Durable Medical Equipment Prescription

DG Diagnostic Report

DJ Discharge Monitoring Report

DS Discharge Summary

EB Explanation of Benefits (Coordination of Benefits orMedicare Secondary Payor)

HC Health Certificate

HR Health Clinic Records

I5 Immunization Record

005010X223 • 837 • 2400 • PWK ASC X12N • INSURANCE SUBCOMMITTEELINE SUPPLEMENTAL INFORMATION TECHNICAL REPORT • TYPE 3

430 MAY 2006

IR State School Immunization Records

LA Laboratory Results

M1 Medical Record Attachment

MT Models

NN Nursing Notes

OB Operative Note

OC Oxygen Content Averaging Report

OD Orders and Treatments Document

OE Objective Physical Examination (including vitalsigns) Document

OX Oxygen Therapy Certification

OZ Support Data for Claim

P4 Pathology Report

P5 Patient Medical History Document

PE Parenteral or Enteral Certification

PN Physical Therapy Notes

PO Prosthetics or Orthotic Certification

PQ Paramedical Results

PY Physician’s Report

PZ Physical Therapy Certification

RB Radiology Films

RR Radiology Reports

RT Report of Tests and Analysis Report

RX Renewable Oxygen Content Averaging Report

SG Symptoms Document

V5 Death Notification

XP PhotographsREQUIRED PWK02 756 Report Transmission Code O 1 ID 1/2

Code defining timing, transmission method or format by which reports are to besent

IMPLEMENTATION NAME: Attachment Transmission Code

CODE DEFINITION

AA Available on Request at Provider Site

179 This means that the additional information is notbeing sent with the claim at this time. Instead, it isavailable to the payer (or appropriate entity) at theirrequest.

BM By Mail

EL Electronically Only

180 Indicates that the attachment is being transmitted ina separate X12 functional group.

EM E-Mail

FT File Transfer

1523 Required when the actual attachment is maintainedby an attachment warehouse or similar vendor.

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • PWKTECHNICAL REPORT • TYPE 3 LINE SUPPLEMENTAL INFORMATION

MAY 2006 431

FX By FaxNOT USED PWK03 757 Report Copies Needed O 1 N0 1/2

NOT USED PWK04 98 Entity Identifier Code O 1 ID 2/3

SITUATIONAL PWK05 66 Identification Code Qualifier X 1 ID 1/2Code designating the system/method of code structure used for IdentificationCode (67)

SYNTAX: P0506

COMMENT: PWK05 and PWK06 may be used to identify the addressee by a codenumber.


CODE DEFINITION

AC Attachment Control NumberSITUATIONAL PWK06 67 Identification Code X 1 AN 2/80


SYNTAX: P0506


IMPLEMENTATION NAME: Attachment Control Number

1494 PWK06 is used to identify the attached electronic documentation.The number in PWK06 is carried in the TRN of the electronicattachment.

1495 For the purpose of this implementation, the maximum field lengthis 50.

NOT USED PWK07 352 Description O 1 AN 1/80

NOT USED PWK08 C002 ACTIONS INDICATED O 1

NOT USED PWK09 1525 Request Category Code O 1 ID 1/2

005010X223 • 837 • 2400 • PWK ASC X12N • INSURANCE SUBCOMMITTEELINE SUPPLEMENTAL INFORMATION TECHNICAL REPORT • TYPE 3

432 MAY 2006

DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2400 • DTPDATE - SERVICE DATE

SEGMENT DETAIL

905 DTP - DATE - SERVICE DATEX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: SITUATIONAL

364 Situational Rule: Required on outpatient service lines where a drug is not being billed andthe Statement Covers Period is greater than one day.ORRequired on service lines where a drug is being billed and the payer’sadjudication is known to be impacted by the drug duration or the date theprescription was written.If not required by this implementation guide, do not send.

365 TR3 Notes: 1. In cases where a drug is being billed on a service line, date range maybe used to indicate drug duration for which the drug supply will beused by the patient. The difference in dates, including both the beginand end dates, are the days supply of the drug. Example: 20000101 -20000107 (1/1/00 to 1/7/00) is used for a 7 day supply where the firstday of the drug used by the patient is 1/1/00. In the event a drug isadministered on less than a daily basis (for example, every other day)the date range would include the entire period during which the drugwas supplied, including the last day the drug was used. Example:20000101 - 20000108 (1/1/00 to 1/8/00) is used for an 8 days supplywhere the prescription is written for Q48 (every 48 hours), four dosesof the drug are dispensed and the first dose is used on 1/1/00.

366 2. In cases where a drug is being billed on a service line, a single datemay be used to indicate the date the prescription was written (orotherwise communicated by the prescriber if not written).

363 TR3 Example: DTP✽ 472✽ D8✽ 20060108~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • DTPTECHNICAL REPORT • TYPE 3 DATE - SERVICE DATE

MAY 2006 433

tdrinkard

Text Box


ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

472 ServiceREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



367 RD8 is required only when the “To and From” dates are different.However, at the discretion of the submitter, RD8 can also be usedwhen the “To and From” dates are the same.

CODE DEFINITION




IMPLEMENTATION NAME: Service Date

005010X223 • 837 • 2400 • DTP ASC X12N • INSURANCE SUBCOMMITTEEDATE - SERVICE DATE TECHNICAL REPORT • TYPE 3

434 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2400 • REFLINE ITEM CONTROL NUMBER

SEGMENT DETAIL

951 REF - LINE ITEM CONTROL NUMBERX12 Segment Name: Reference Information




Segment Repeat: 1

Usage: SITUATIONAL

952 Situational Rule: Required when the submitter needs a line item control number forsubsequent communications to or from the payer. If not required by thisimplementation guide, do not send.

953 TR3 Notes: 1. The line item control number must be unique within a patient controlnumber (CLM01). Payers are required to return this number in theremittance advice transaction (835) if the provider sends it to them inthe 837 and adjudication is based upon line item detail regardless ofwhether bundling or unbundling has occurred.

954 2. Submitters are STRONGLY encouraged to routinely send a unique lineitem control number on all service lines, particularly if the submitterautomatically posts their remittance advice. Submitting a unique lineitem control number allows the capability to automatically post byservice line.

950 TR3 Example: REF✽ 6R✽ 54321~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

6R Provider Control Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • REFTECHNICAL REPORT • TYPE 3 LINE ITEM CONTROL NUMBER

MAY 2006 435


SYNTAX: R0203

IMPLEMENTATION NAME: Line Item Control Number

955 The maximum number of characters to be supported for this field is‘30’. A submitter may submit fewer characters depending upontheir needs. However, the HIPAA maximum requirement to besupported by any receiving system is ‘30’. Characters beyond 30are not required to be stored nor returned by any 837-receivingsystem.



005010X223 • 837 • 2400 • REF ASC X12N • INSURANCE SUBCOMMITTEELINE ITEM CONTROL NUMBER TECHNICAL REPORT • TYPE 3

436 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2400 • REFREPRICED LINE ITEM REFERENCE NUMBER

SEGMENT DETAIL

943 REF - REPRICED LINE ITEM REFERENCENUMBER





Segment Repeat: 1

Usage: SITUATIONAL

944 Situational Rule: Required when a repricing (pricing) organization needs to have anidentifying number on the service line in their submission to their payerorganization. This segment is not completed by providers. If not requiredby this implementation guide, do not send.

942 TR3 Example: REF✽ 9B✽ 444444~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9B Repriced Line Item Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Repriced Line Item Reference Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • REFTECHNICAL REPORT • TYPE 3 REPRICED LINE ITEM REFERENCE NUMBER

MAY 2006 437

REFREFERENCE INFORMATION 005010X223 • 837 • 2400 • REFADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

SEGMENT DETAIL

946 REF - ADJUSTED REPRICED LINE ITEMREFERENCE NUMBER





Segment Repeat: 1

Usage: SITUATIONAL

947 Situational Rule: Required when a repricing (pricing) organization needs to have anidentifying number on an adjusted service line in their submission to theirpayer organization. This segment is not completed by providers. If notrequired by this implementation guide, do not send.

945 TR3 Example: REF✽ 9D✽ 444444~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

9D Adjusted Repriced Line Item Reference NumberREQUIRED REF02 127 Reference Identification X 1 AN 1/50


SYNTAX: R0203

IMPLEMENTATION NAME: Adjusted Repriced Line Item Reference Number



005010X223 • 837 • 2400 • REF ASC X12N • INSURANCE SUBCOMMITTEEADJUSTED REPRICED LINE ITEM REFERENCE NUMBER TECHNICAL REPORT • TYPE 3

438 MAY 2006

SITUATIONAL REF04 C040 REFERENCE IDENTIFIER O 1To identify one or more reference numbers or identification numbers as specifiedby the Reference Qualifier

SYNTAX:

P0304If either C04003 or C04004 is present, then the other is required.P0506If either C04005 or C04006 is present, then the other is required.

1570 SITUATIONAL RULE: Required when the Predetermination Identificationreported in REF02 of this segment is for a non-destination payer.

REQUIRED REF04 - 1 128 Reference Identification Qualifier M ID 2/3Code qualifying the Reference Identification

CODE DEFINITION

2U Payer Identification NumberREQUIRED REF04 - 2 127 Reference Identification M AN 1/50

Reference information as defined for a particular Transaction Set or asspecified by the Reference Identification Qualifier


1569 The payer identifier reported in this field must match thecooresponding payer identifier reported in Loop ID-2330BNM109.

NOT USED REF04 - 3 128 Reference Identification Qualifier X ID 2/3

NOT USED REF04 - 4 127 Reference Identification X AN 1/50



ASC X12N • INSURANCE SUBCOMMITTEE 005010X224 • 837 • 2400 • REFTECHNICAL REPORT • TYPE 3 SERVICE PREDETERMINATION IDENTIFICATION

MAY 2006 299

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2400 • AMTSERVICE TAX AMOUNT

SEGMENT DETAIL

1443 AMT - SERVICE TAX AMOUNTX12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

1444 Situational Rule: Required when a service tax or surcharge applies to the service beingreported in SV201 and the submitter is required to report that informationto the receiver. If not required by this implementation guide, do not send.

1446 TR3 Notes: 1. When reporting the Service Tax Amount (AMT02), the amountreported in the Line Item Charge Amount (SV203) for this service linemust include the amount reported in the Service Tax Amount.

1445 TR3 Example: AMT✽ GT✽ 15~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478



M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

GT Goods and Services TaxREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Service Tax Amount


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • AMTTECHNICAL REPORT • TYPE 3 SERVICE TAX AMOUNT

MAY 2006 439

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2400 • AMTFACILITY TAX AMOUNT

SEGMENT DETAIL

1447 AMT - FACILITY TAX AMOUNTX12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

1544 Situational Rule: Required when a facility tax or surcharge applies to the service beingreported in SV201 and the submitter is required to report that informationto the receiver. If not required by this implementation guide, do not send.

1449 TR3 Notes: 1. When reporting the Facility Tax Amount (AMT02), the amount reportedin the Line Item Charge Amount (SV203) for this service line mustinclude the amount reported in the Facility Tax Amount.

1448 TR3 Example: AMT✽ N8✽ 22~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478



M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

N8 Miscellaneous TaxesREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Facility Tax Amount


005010X223 • 837 • 2400 • AMT ASC X12N • INSURANCE SUBCOMMITTEEFACILITY TAX AMOUNT TECHNICAL REPORT • TYPE 3

440 MAY 2006

NTENOTE/SPECIAL INSTRUCTION 005010X223 • 837 • 2400 • NTETHIRD PARTY ORGANIZATION NOTES

SEGMENT DETAIL

1450 NTE - THIRD PARTY ORGANIZATION NOTESX12 Segment Name: Note/Special Instruction




Segment Repeat: 1

Usage: SITUATIONAL

1452 Situational Rule: Required when the TPO/repricer needs to forward additional informationto the payer. This segment is not completed by providers. If not requiredby this implementation guide, do not send.

1451 TR3 Example: NTE✽ TPO✽ state regulation 123 was applied during the pricing of thisclaim~

DIAGRAM

NTE01 363 NTE02 352


~

O 1 ID 3/3 M 1 AN 1/80

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

TPO Third Party Organization NotesREQUIRED NTE02 352 Description M 1 AN 1/80


IMPLEMENTATION NAME: Line Note Text

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • NTETECHNICAL REPORT • TYPE 3 THIRD PARTY ORGANIZATION NOTES

MAY 2006 441

HCPHEALTH CARE PRICING 005010X223 • 837 • 2400 • HCPLINE PRICING/REPRICING INFORMATION

SEGMENT DETAIL

990 HCP - LINE PRICING/REPRICINGINFORMATION

X12 Segment Name: Health Care Pricing

X12 Purpose: To specify pricing or repricing information about a health care claim or line item

X12 Syntax: 1. R0113At least one of HCP01 or HCP13 is required.




Segment Repeat: 1

Usage: SITUATIONAL



667 2. For capitated encounters, pricing or repricing information usually isnot applicable and is provided to qualify other information within theclaim.

665 TR3 Example: HCP✽ 03✽ 100✽ 10✽ RPO12345~

DIAGRAM


HCP ✽ PricingMethodology ✽ Monetary

Amount ✽ MonetaryAmount ✽ Reference

Ident ✽ Rate ✽ ReferenceIdent

X 1 ID 2/2 O 1 R 1/18 O 1 R 1/18 O 1 AN 1/50 O 1 R 1/9 O 1 AN 1/50


✽ MonetaryAmount ✽ Product/

Service ID ✽ Prod/ServID Qual ✽ Product/

Service ID ✽ Unit/BasisMeas Code ✽ Quantity

O 1 R 1/18 O 1 AN 1/48 X 1 ID 2/2 X 1 AN 1/48 X 1 ID 2/2 X 1 R 1/15

HCP13 901 HCP14 1526 HCP15 1527

✽ RejectReason Code ✽ Policy Comp

Code ✽ ExceptionCode ~

X 1 ID 2/2 O 1 ID 1/2 O 1 ID 1/2

005010X223 • 837 • 2400 • HCP ASC X12N • INSURANCE SUBCOMMITTEELINE PRICING/REPRICING INFORMATION TECHNICAL REPORT • TYPE 3

442 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED HCP01 1473 Pricing Methodology X 1 ID 2/2Code specifying pricing methodology at which the claim or line item has beenpriced or repriced

SYNTAX: R0113

668 Specific code use is determined by Trading Partner Agreement dueto the variances in contracting policies in the industry.

CODE DEFINITION

00 Zero Pricing (Not Covered Under Contract)

01 Priced as Billed at 100%

02 Priced at the Standard Fee Schedule

03 Priced at a Contractual Percentage

04 Bundled Pricing

05 Peer Review Pricing

06 Per Diem Pricing

07 Flat Rate Pricing

08 Combination Pricing

09 Maternity Pricing

10 Other Pricing

11 Lower of Cost

12 Ratio of Cost

13 Cost Reimbursed

14 Adjustment PricingREQUIRED HCP02 782 Monetary Amount O 1 R 1/18

Monetary amount

SEMANTIC: HCP02 is the allowed amount.


SEMANTIC: HCP03 is the savings amount.



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2400 • HCPTECHNICAL REPORT • TYPE 3 LINE PRICING/REPRICING INFORMATION

MAY 2006 443


SEMANTIC: HCP04 is the repricing organization identification number.



SITUATIONAL HCP05 118 Rate O 1 R 1/9Rate expressed in the standard monetary denomination for the currency specified

SEMANTIC: HCP05 is the pricing rate associated with per diem or flat rate repricing.




SEMANTIC: HCP06 is the approved DRG code.

COMMENT: HCP06, HCP07, HCP08, HCP10, and HCP12 are fields that will containdifferent values from the original submitted values.




SEMANTIC: HCP07 is the approved DRG amount.




444 MAY 2006

SITUATIONAL HCP08 234 Product/Service ID O 1 AN 1/48Identifying number for a product or service

SEMANTIC: HCP08 is the approved revenue code.


IMPLEMENTATION NAME: Product or Service ID


SITUATIONAL HCP09 235 Product/Service ID Qualifier X 1 ID 2/2Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

SYNTAX: P0910

1382 SITUATIONAL RULE: Required when HCP10 exists. If not required by thisimplementation guide, do not send.


CODE DEFINITION


1529 This code set is not allowed for use under HIPAA atthe time of this writing. The qualifier can only beused:If a new rule names the Jurisdiction SpecificProcedure and Supply Codes as an allowable codeset under HIPAA, ORThe Secretary grants an exception to use the codeset as a pilot project as allowed under the law, ORFor claims which are not covered under HIPAA.








MAY 2006 445






CODE SOURCE 843: Advanced Billing Concepts (ABC) CodesSITUATIONAL HCP10 234 Product/Service ID X 1 AN 1/48


SYNTAX: P0910

SEMANTIC: HCP10 is the approved procedure code.


IMPLEMENTATION NAME: Repriced Approved HCPCS Code



446 MAY 2006

SITUATIONAL HCP11 355 Unit or Basis for Measurement Code X 1 ID 2/2Code specifying the units in which a value is being expressed, or manner in whicha measurement has been taken

SYNTAX: P1112


CODE DEFINITION

DA Days

UN UnitSITUATIONAL HCP12 380 Quantity X 1 R 1/15


SYNTAX: P1112

SEMANTIC: HCP12 is the approved service units or inpatient days.




SITUATIONAL HCP13 901 Reject Reason Code X 1 ID 2/2Code assigned by issuer to identify reason for rejection

SYNTAX: R0113

SEMANTIC: HCP13 is the rejection message returned from the third partyorganization.



CODE DEFINITION

T1 Cannot Identify Provider as TPO (Third PartyOrganization) Participant

T2 Cannot Identify Payer as TPO (Third PartyOrganization) Participant

T3 Cannot Identify Insured as TPO (Third PartyOrganization) Participant

T4 Payer Name or Identifier Missing

T5 Certification Information Missing

T6 Claim does not contain enough information for re-pricing


MAY 2006 447

SITUATIONAL HCP14 1526 Policy Compliance Code O 1 ID 1/2Code specifying policy compliance



CODE DEFINITION

1 Procedure Followed (Compliance)

2 Not Followed - Call Not Made (Non-Compliance CallNot Made)

3 Not Medically Necessary (Non-Compliance Non-Medically Necessary)

4 Not Followed Other (Non-Compliance Other)

5 Emergency Admit to Non-Network HospitalSITUATIONAL HCP15 1527 Exception Code O 1 ID 1/2

Code specifying the exception reason for consideration of out-of-network healthcare services

SEMANTIC: HCP15 is the exception reason generated by a third party organization.



CODE DEFINITION

1 Non-Network Professional Provider in NetworkHospital

2 Emergency Care

3 Services or Specialist not in Network

4 Out-of-Service Area

5 State Mandates

6 Other


448 MAY 2006

LINITEM IDENTIFICATION 005010X223 • 837 • 2410 • LINDRUG IDENTIFICATION

SEGMENT DETAIL

992 LIN - DRUG IDENTIFICATIONX12 Segment Name: Item Identification

X12 Purpose: To specify basic item identification data

X12 Set Notes: 1. Loop 2410 contains compound drug components, quantities and prices.

X12 Syntax: 1. P0405If either LIN04 or LIN05 is present, then the other is required.

2. P0607If either LIN06 or LIN07 is present, then the other is required.













X12 Comments: 1. See the Data Dictionary for a complete list of IDs.

Loop: 2410 — DRUG IDENTIFICATION Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2410 • LINTECHNICAL REPORT • TYPE 3 DRUG IDENTIFICATION

MAY 2006 449

994 Situational Rule: Required when government regulation mandates that prescribed drugsand biologics are reported with NDC numbers.ORRequired when the provider or submitter chooses to report NDC numbersto enhance the claim reporting or adjudication processes.If not required by this implementation guide, do not send.

1593 TR3 Notes: 1. Drugs and biologics reported in this segment are a furtherspecification of service(s) described in the SV2 segment of thisService Line Loop ID-2400.

993 TR3 Example: LIN✽✽ N4✽ 01234567891~

DIAGRAM

LIN01 350 LIN02 235 LIN03 234 LIN04 235 LIN05 234 LIN06 235

LIN ✽ AssignedID ✽ Prod/Serv

ID Qual ✽ Product/Service ID ✽ Prod/Serv


ID QualO 1 AN 1/20 M 1 ID 2/2 M 1 AN 1/48 X 1 ID 2/2 X 1 AN 1/48 X 1 ID 2/2


✽ Product/Service ID ✽ Prod/Serv



ID QualX 1 AN 1/48 X 1 ID 2/2 X 1 AN 1/48 X 1 ID 2/2 X 1 AN 1/48 X 1 ID 2/2
















LIN31 234

✽ Product/Service ID ~

X 1 AN 1/48

ELEMENT DETAIL

USAGEREF.DES.


NOT USED LIN01 350 Assigned Identification O 1 AN 1/20

005010X223 • 837 • 2410 • LIN ASC X12N • INSURANCE SUBCOMMITTEEDRUG IDENTIFICATION TECHNICAL REPORT • TYPE 3

450 MAY 2006

REQUIRED LIN02 235 Product/Service ID Qualifier M 1 ID 2/2Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

COMMENT: LIN02 through LIN31 provide for fifteen different product/service IDs foreach item. For example: Case, Color, Drawing No., U.P.C. No., ISBN No., ModelNo., or SKU.


CODE DEFINITION

N4 National Drug Code in 5-4-2 Format

CODE SOURCE 240: National Drug Code by FormatREQUIRED LIN03 234 Product/Service ID M 1 AN 1/48


IMPLEMENTATION NAME: National Drug Code

NOT USED LIN04 235 Product/Service ID Qualifier X 1 ID 2/2

NOT USED LIN05 234 Product/Service ID X 1 AN 1/48



























ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2410 • LINTECHNICAL REPORT • TYPE 3 DRUG IDENTIFICATION

MAY 2006 451

CTPPRICING INFORMATION 005010X223 • 837 • 2410 • CTPDRUG QUANTITY

SEGMENT DETAIL

996 CTP - DRUG QUANTITYX12 Segment Name: Pricing Information

X12 Purpose: To specify pricing information

X12 Syntax: 1. P0405If either CTP04 or CTP05 is present, then the other is required.

2. C0607If CTP06 is present, then CTP07 is required.




Loop: 2410 — DRUG IDENTIFICATION

Segment Repeat: 1

Usage: REQUIRED

997 TR3 Example: CTP✽✽✽✽ 2✽ UN~

DIAGRAM

CTP01 687 CTP02 236 CTP03 212 CTP04 380 CTP05 C001 CTP06 648

CTP ✽ Class ofTrade Code ✽ Price ID

Code ✽ UnitPrice ✽ Quantity ✽ Composite

Unit of Mea ✽ Price MultQualifier

O 1 ID 2/2 X 1 ID 3/3 X 1 R 1/17 X 1 R 1/15 X 1 O 1 ID 3/3

CTP07 649 CTP08 782 CTP09 639 CTP10 499 CTP11 289

✽ Multiplier ✽ MonetaryAmount ✽ Basis Unit

Price Code ✽ ConditionValue ✽ Mult Price

Quantity ~

X 1 R 1/10 O 1 R 1/18 O 1 ID 2/2 O 1 AN 1/10 O 1 N0 1/2

ELEMENT DETAIL

USAGEREF.DES.


NOT USED CTP01 687 Class of Trade Code O 1 ID 2/2

NOT USED CTP02 236 Price Identifier Code X 1 ID 3/3

NOT USED CTP03 212 Unit Price X 1 R 1/17

REQUIRED CTP04 380 Quantity X 1 R 1/15Numeric value of quantity

SYNTAX: P0405

IMPLEMENTATION NAME: National Drug Unit Count

005010X223 • 837 • 2410 • CTP ASC X12N • INSURANCE SUBCOMMITTEEDRUG QUANTITY TECHNICAL REPORT • TYPE 3

452 MAY 2006

REQUIRED CTP05 C001 COMPOSITE UNIT OF MEASURE X 1To identify a composite unit of measure

REQUIRED CTP05 - 1 355 Unit or Basis for Measurement Code M ID 2/2Code specifying the units in which a value is being expressed, ormanner in which a measurement has been taken

COMMENTS:

If C001-11 is not used, its value is to be interpreted as 1.If C001-12 is not used, its value is to be interpreted as 1.If C001-14 is not used, its value is to be interpreted as 1.If C001-15 is not used, its value is to be interpreted as 1.

IMPLEMENTATION NAME: Code Qualifier

CODE DEFINITION

F2 International Unit

GR Gram

ME Milligram

ML Milliliter

UN UnitNOT USED CTP05 - 2 1018 Exponent O R 1/15

NOT USED CTP05 - 3 649 Multiplier O R 1/10

NOT USED CTP05 - 4 355 Unit or Basis for Measurement Code O ID 2/2

NOT USED CTP05 - 5 1018 Exponent O R 1/15











NOT USED CTP06 648 Price Multiplier Qualifier O 1 ID 3/3

NOT USED CTP07 649 Multiplier X 1 R 1/10

NOT USED CTP08 782 Monetary Amount O 1 R 1/18

NOT USED CTP09 639 Basis of Unit Price Code O 1 ID 2/2

NOT USED CTP10 499 Condition Value O 1 AN 1/10

NOT USED CTP11 289 Multiple Price Quantity O 1 N0 1/2

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2410 • CTPTECHNICAL REPORT • TYPE 3 DRUG QUANTITY

MAY 2006 453

REFREFERENCE INFORMATION 005010X223 • 837 • 2410 • REFPRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER

SEGMENT DETAIL

1000 REF - PRESCRIPTION OR COMPOUND DRUGASSOCIATION NUMBER




Loop: 2410 — DRUG IDENTIFICATION

Segment Repeat: 1

Usage: SITUATIONAL

1001 Situational Rule: Required when dispensing of the drug has been done with an assignedprescription number.ORRequired when the provided medication involves the compounding of twoor more drugs being reported and there is no prescription number.If not required by this implementation guide, do not send.

1002 TR3 Notes: 1. In cases where a compound drug is being billed, the components ofthe compound will all have the same prescription number. Payersreceiving the claim can relate all the components by matching theprescription number.

1003 2. For cases where the drug is provided without a prescription (forexample, from a physician’s office), the value provided in thissegment is a “link sequence number”. The link sequence number is aprovider assigned number that is unique to this claim. Its purpose isto enable the receiver to piece together the components of thecompound.

999 TR3 Example: REF✽ XZ✽ 123456~

DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

VY Link Sequence Number

XZ Pharmacy Prescription Number

005010X223 • 837 • 2410 • REF ASC X12N • INSURANCE SUBCOMMITTEEPRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER TECHNICAL REPORT • TYPE 3

454 MAY 2006


SYNTAX: R0203

IMPLEMENTATION NAME: Prescription Number



ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2410 • REFTECHNICAL REPORT • TYPE 3 PRESCRIPTION OR COMPOUND DRUG ASSOCIATION NUMBER

MAY 2006 455

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2420A • NM1OPERATING PHYSICIAN NAME

SEGMENT DETAIL

273 NM1 - OPERATING PHYSICIAN NAMEX12 Segment Name: Individual or Organizational Name


X12 Set Notes: 1. Loop 2420 contains information about the rendering, referring, or attendingprovider on a service line level. These segments override the information inthe claim - level segments if the entity identifier codes in each NM1segment are the same.




Loop: 2420A — OPERATING PHYSICIAN NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

368 Situational Rule: Required when a surgical procedure code is listed on this claim.ANDThe Operating Physician for this line is different than the OperatingPhysician reported in Loop ID-2310B (claim level).If not required by this implementation guide, do not send.

276 TR3 Notes: 1. The Operating Physician is the individual with primary responsibilityfor performing the surgical procedure(s).

275 TR3 Example: NM1✽ 72✽ 1✽ MEYERS✽ JANE✽✽✽✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2420A • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

456 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Operating Physician Last Name



IMPLEMENTATION NAME: Operating Physician First Name



IMPLEMENTATION NAME: Operating Physician Middle Name or Initial




IMPLEMENTATION NAME: Operating Physician Name Suffix

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420A • NM1TECHNICAL REPORT • TYPE 3 OPERATING PHYSICIAN NAME

MAY 2006 457


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Operating Physician Primary Identifier




005010X223 • 837 • 2420A • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

458 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2420A • REFOPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

278 REF - OPERATING PHYSICIAN SECONDARYIDENTIFICATION




Loop: 2420A — OPERATING PHYSICIAN NAME

Segment Repeat: 20

Usage: SITUATIONAL


1575 TR3 Notes: 1. When it is necessary to report one or more non-destination payerSecondary Identifiers, the composite data element in REF04 is used toidentify the payer who assigned this identifier.


DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420A • REFTECHNICAL REPORT • TYPE 3 OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 459





SYNTAX: R0203

IMPLEMENTATION NAME: Operating Physician Secondary Identifier



SYNTAX:


1576 SITUATIONAL RULE: Required when the identifier reported in REF02 ofthis segment is for a non-destination payer.

1577 Do not use this composite when the value reported in REF01 iseither 0B or 1G.


CODE DEFINITION









005010X223 • 837 • 2420A • REF ASC X12N • INSURANCE SUBCOMMITTEEOPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

460 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2420B • NM1OTHER OPERATING PHYSICIAN NAME

SEGMENT DETAIL

279 NM1 - OTHER OPERATING PHYSICIAN NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2420B — OTHER OPERATING PHYSICIAN NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

371 Situational Rule: Required when another Operating Physician is involved, ANDThe Other Operating Physician for this line is different than the OtherOperating Physician reported in Loop ID-2310C (claim level).If not required by this implementation guide, do not send.

370 TR3 Example: NM1✽ ZZ✽ 1✽ JONES✽ JOHN✽✽✽ SR✽ XX✽ 1234567891~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420B • NM1TECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN NAME

MAY 2006 461

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

ZZ Mutually Defined




CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Other Operating Physician Last Name



IMPLEMENTATION NAME: Other Operating Physician First Name



IMPLEMENTATION NAME: Other Operating Physician Middle Name or Initial




IMPLEMENTATION NAME: Other Operating Physician Name Suffix

005010X223 • 837 • 2420B • NM1 ASC X12N • INSURANCE SUBCOMMITTEEOTHER OPERATING PHYSICIAN NAME TECHNICAL REPORT • TYPE 3

462 MAY 2006


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Other Operating Physician Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420B • NM1TECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN NAME

MAY 2006 463

REFREFERENCE INFORMATION 005010X223 • 837 • 2420B • REFOTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

SEGMENT DETAIL

285 REF - OTHER OPERATING PHYSICIANSECONDARY IDENTIFICATION




Loop: 2420B — OTHER OPERATING PHYSICIAN NAME

Segment Repeat: 20

Usage: SITUATIONAL




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




005010X223 • 837 • 2420B • REF ASC X12N • INSURANCE SUBCOMMITTEEOTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

464 MAY 2006





SYNTAX: R0203

IMPLEMENTATION NAME: Other Provider Secondary Identifier



SYNTAX:





CODE DEFINITION









ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420B • REFTECHNICAL REPORT • TYPE 3 OTHER OPERATING PHYSICIAN SECONDARY IDENTIFICATION

MAY 2006 465

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2420C • NM1RENDERING PROVIDER NAME

SEGMENT DETAIL

689 NM1 - RENDERING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2420C — RENDERING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

1457 Situational Rule: Required when Rendering Provider is different than the AttendingProvider reported in the 2310A loop of this claim.ANDState or federal regulatory requirements call for a “combined claim”, thatis, a claim that includes both facility and professional components (forexample, a Medicaid clinic bill or Critical Access Hospital Claim.)ANDThe Rendering Provider for this line is different than the RenderingProvider reported in Loop ID 2310D (claim level).If not required by this implementation guide, do not send.

289 TR3 Notes: 1. The Rendering Provider is the health care professional who deliversor completes a particular medical service or non-surgical procedure.

692 TR3 Example: NM1✽ 82✽ 1✽ DOE✽ JANE✽ C✽✽✽ XX✽ 1234567804~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


005010X223 • 837 • 2420C • NM1 ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER NAME TECHNICAL REPORT • TYPE 3

466 MAY 2006

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Rendering Provider Last Name



IMPLEMENTATION NAME: Rendering Provider First Name



IMPLEMENTATION NAME: Rendering Provider Middle Name or Initial




IMPLEMENTATION NAME: Rendering Provider Name Suffix

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420C • NM1TECHNICAL REPORT • TYPE 3 RENDERING PROVIDER NAME

MAY 2006 467


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Rendering Provider Identifier




005010X223 • 837 • 2420C • NM1 ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER NAME TECHNICAL REPORT • TYPE 3

468 MAY 2006

REFREFERENCE INFORMATION 005010X223 • 837 • 2420C • REFRENDERING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

694 REF - RENDERING PROVIDER SECONDARYIDENTIFICATION




Loop: 2420C — RENDERING PROVIDER NAME

Segment Repeat: 20

Usage: SITUATIONAL




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420C • REFTECHNICAL REPORT • TYPE 3 RENDERING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 469





SYNTAX: R0203

IMPLEMENTATION NAME: Rendering Provider Secondary Identifier



SYNTAX:





CODE DEFINITION









005010X223 • 837 • 2420C • REF ASC X12N • INSURANCE SUBCOMMITTEERENDERING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

470 MAY 2006

NM1INDIVIDUAL OR ORGANIZATIONAL NAME 005010X223 • 837 • 2420D • NM1REFERRING PROVIDER NAME

SEGMENT DETAIL

299 NM1 - REFERRING PROVIDER NAMEX12 Segment Name: Individual or Organizational Name






Loop: 2420D — REFERRING PROVIDER NAME Loop Repeat: 1

Segment Repeat: 1

Usage: SITUATIONAL

1460 Situational Rule: Required on an outpatient claim when the Referring Provider is differentthan the Attending Provider.ANDThe Referring Provider for this line is different than the Referring Providerreported in Loop ID 2310F (claim level).If not required by this implementation guide, do not send.

302 TR3 Notes: 1. The Referring Provider is provider who sends the patient to anotherprovider for services.

1459 TR3 Example: NM1✽ DN✽ 1✽ SMITH✽ JANE✽✽✽✽ XX✽ 1234567890~

DIAGRAM

NM101 98 NM102 1065 NM103 1035 NM104 1036 NM105 1037 NM106 1038





NM107 1039 NM108 66 NM109 67 NM110 706 NM111 98 NM112 1035




Org Name ~


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420D • NM1TECHNICAL REPORT • TYPE 3 REFERRING PROVIDER NAME

MAY 2006 471

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




CODE DEFINITION



SYNTAX: C1203

IMPLEMENTATION NAME: Referring Provider Last Name



IMPLEMENTATION NAME: Referring Provider First Name



IMPLEMENTATION NAME: Referring Provider Middle Name or Initial




IMPLEMENTATION NAME: Referring Provider Name Suffix

005010X223 • 837 • 2420D • NM1 ASC X12N • INSURANCE SUBCOMMITTEEREFERRING PROVIDER NAME TECHNICAL REPORT • TYPE 3

472 MAY 2006


SYNTAX: P0809


CODE DEFINITION




SYNTAX: P0809


IMPLEMENTATION NAME: Referring Provider Identifier




ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420D • NM1TECHNICAL REPORT • TYPE 3 REFERRING PROVIDER NAME

MAY 2006 473

REFREFERENCE INFORMATION 005010X223 • 837 • 2420D • REFREFERRING PROVIDER SECONDARY IDENTIFICATION

SEGMENT DETAIL

304 REF - REFERRING PROVIDER SECONDARYIDENTIFICATION




Loop: 2420D — REFERRING PROVIDER NAME

Segment Repeat: 20

Usage: SITUATIONAL




DIAGRAM

REF01 128 REF02 127 REF03 352 REF04 C040



M 1 ID 2/3 X 1 AN 1/50 X 1 AN 1/80 O 1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION




005010X223 • 837 • 2420D • REF ASC X12N • INSURANCE SUBCOMMITTEEREFERRING PROVIDER SECONDARY IDENTIFICATION TECHNICAL REPORT • TYPE 3

474 MAY 2006




SYNTAX: R0203

IMPLEMENTATION NAME: Referring Provider Secondary Identifier



SYNTAX:





CODE DEFINITION









ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2420D • REFTECHNICAL REPORT • TYPE 3 REFERRING PROVIDER SECONDARY IDENTIFICATION

MAY 2006 475

SVDSERVICE LINE ADJUDICATION 005010X223 • 837 • 2430 • SVDLINE ADJUDICATION INFORMATION

SEGMENT DETAIL

1032 SVD - LINE ADJUDICATION INFORMATIONX12 Segment Name: Service Line Adjudication

X12 Purpose: To convey service line adjudication information for coordination of benefitsbetween the initial payers of a health care claim and all subsequent payers

X12 Set Notes: 1. SVD01 identifies the payer which adjudicated the corresponding serviceline and must match DE 67 in the NM109 position 325 for the payer.

Loop: 2430 — LINE ADJUDICATION INFORMATION Loop Repeat: 15

Segment Repeat: 1

Usage: SITUATIONAL

1033 Situational Rule: Required when the claim has been previously adjudicated by payeridentified in Loop ID-2330B and this service line has payments and/oradjustments applied to it. If not required by this implementation guide, donot send.

1034 TR3 Notes: 1. To show unbundled lines: If, in the original claim, line 3 is unbundledinto (for example) 2 additional lines, then the SVD for line 3 is used 3times: once for the original adjustment to line 3 and then two moretimes for the additional unbundled lines.

1031 TR3 Example: SVD✽ 43✽ 55✽ HC:84550✽✽ 3~

DIAGRAM

SVD01 67 SVD02 782 SVD03 C003 SVD04 234 SVD05 380 SVD06 554

SVD ✽ IDCode ✽ Monetary

Amount ✽ Comp. Med.Proced. ID ✽ Product/

Service ID ✽ Quantity ✽ AssignedNumber ~

M 1 AN 2/80 M 1 R 1/18 O 1 O 1 AN 1/48 O 1 R 1/15 O 1 N0 1/6

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED SVD01 67 Identification Code M 1 AN 2/80Code identifying a party or other code

SEMANTIC: SVD01 is the payer identification code.


1035 This identifier indicates the payer responsible for thereimbursement described in this iteration of the 2430 loop. Theidentifier indicates the Other Payer by matching the appropriateOther Payer Primary Identifier (Loop ID-2330B, element NM109).

005010X223 • 837 • 2430 • SVD ASC X12N • INSURANCE SUBCOMMITTEELINE ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

476 MAY 2006

tdrinkard

Text Box

Remove the 2430 loop.

REQUIRED SVD02 782 Monetary Amount M 1 R 1/18Monetary amount

SEMANTIC: SVD02 is the amount paid for this service line.

IMPLEMENTATION NAME: Service Line Paid Amount

843 Zero “0” is an acceptable value for this element.

REQUIRED SVD03 C003 COMPOSITE MEDICAL PROCEDUREIDENTIFIER

O 1

To identify a medical procedure by its standardized codes and applicablemodifiers

1036 This element contains the procedure code that was used to pay thisservice line.

REQUIRED SVD03 - 1 235 Product/Service ID Qualifier M ID 2/2Code identifying the type/source of the descriptive number used inProduct/Service ID (234)

SEMANTIC:



CODE DEFINITION











ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2430 • SVDTECHNICAL REPORT • TYPE 3 LINE ADJUDICATION INFORMATION

MAY 2006 477



CODE SOURCE 843: Advanced Billing Concepts (ABC) CodesREQUIRED SVD03 - 2 234 Product/Service ID M AN 1/48


SEMANTIC:

If C003-08 is used, then C003-02 represents the beginning value in therange in which the code occurs.


SITUATIONAL SVD03 - 3 1339 Procedure Modifier O AN 2/2This identifies special circumstances related to the performance of theservice, as defined by trading partners

SEMANTIC:


355 SITUATIONAL RULE: Required when a modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. This is the first procedure code modifier. Ifnot required by this implementation guide, do not send.


SEMANTIC:


356 SITUATIONAL RULE: Required when a second modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.


SEMANTIC:


357 SITUATIONAL RULE: Required when a third modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.

005010X223 • 837 • 2430 • SVD ASC X12N • INSURANCE SUBCOMMITTEELINE ADJUDICATION INFORMATION TECHNICAL REPORT • TYPE 3

478 MAY 2006


SEMANTIC:


358 SITUATIONAL RULE: Required when a fourth modifier clarifies orimproves the reporting accuracy of the associatedprocedure code. If not required by this implementationguide, do not send.

SITUATIONAL SVD03 - 7 352 Description O AN 1/80A free-form description to clarify the related data elements and theircontent

SEMANTIC:

C003-07 is the description of the procedure identified in C003-02.

1037 SITUATIONAL RULE: Required when SVC01-7 was returned in the835 transaction. If not required by this implementationguide, do not send.

IMPLEMENTATION NAME: Procedure Code Description

NOT USED SVD03 - 8 234 Product/Service ID O AN 1/48

NOT USED SVD04 234 Product/Service ID O 1 AN 1/48

REQUIRED SVD05 380 Quantity O 1 R 1/15Numeric value of quantity

SEMANTIC: SVD05 is the paid units of service.

IMPLEMENTATION NAME: Paid Service Unit Count

1038 This is the number of paid units from the remittance advice. Whenpaid units are not present on the remittance advice, use the originalbilled units.


SITUATIONAL SVD06 554 Assigned Number O 1 N0 1/6Number assigned for differentiation within a transaction set

COMMENT: SVD06 is only used for bundling of service lines. It references the LXAssigned Number of the service line into which this service line was bundled.

1040 SITUATIONAL RULE: Required when payer bundled this service line. If notrequired by this implementation guide, do not send.

IMPLEMENTATION NAME: Bundled Line Number

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2430 • SVDTECHNICAL REPORT • TYPE 3 LINE ADJUDICATION INFORMATION

MAY 2006 479

CASCLAIMS ADJUSTMENT 005010X223 • 837 • 2430 • CASLINE ADJUSTMENT

SEGMENT DETAIL

1042 CAS - LINE ADJUSTMENTX12 Segment Name: Claims Adjustment

X12 Purpose: To supply adjustment reason codes and amounts as needed for an entire claimor for a particular service within the claim being paid

X12 Syntax: 1. L050607If CAS05 is present, then at least one of CAS06 or CAS07 are required.















X12 Comments: 1. Adjustment information is intended to help the provider balance theremittance information. Adjustment amounts should fully explain thedifference between submitted charges and the amount paid.

Loop: 2430 — LINE ADJUDICATION INFORMATION

Segment Repeat: 5

Usage: SITUATIONAL

005010X223 • 837 • 2430 • CAS ASC X12N • INSURANCE SUBCOMMITTEELINE ADJUSTMENT TECHNICAL REPORT • TYPE 3

480 MAY 2006

1041 Situational Rule: Required when the payer identified in Loop 2330B made line leveladjustments which caused the amount paid to differ from the amountoriginally charged. If not required by this implementation guide, do notsend.

743 TR3 Notes: 1. A single CAS segment contains six repetitions of the “adjustmenttrio” composed of adjustment reason code, adjustment amount, andadjustment quantity. These six adjustment trios are used to report upto six adjustments related to a particular Claim Adjustment GroupCode (CAS01). The first non-zero adjustment is reported in the firstadjustment trio (CAS02-CAS04). If there is a second non-zeroadjustment, it is reported in the second adjustment trio (CAS05-CAS07), and so on through the sixth adjustment trio (CAS17-CAS19).

736 TR3 Example: CAS✽ PR✽ 1✽ 7.93~

737 TR3 Example: CAS✽ OA✽ 93✽ 15.06~

DIAGRAM


CAS ✽ Claim AdjGroup Code ✽ Claim Adj

Reason Code ✽ MonetaryAmount ✽ Quantity ✽ Claim Adj

Reason Code ✽ MonetaryAmount

M 1 ID 1/2 M 1 ID 1/5 M 1 R 1/18 O 1 R 1/15 X 1 ID 1/5 X 1 R 1/18









CAS19 380

✽ Quantity~

X 1 R 1/15

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED CAS01 1033 Claim Adjustment Group Code M 1 ID 1/2Code identifying the general category of payment adjustment

CODE DEFINITION

CO Contractual Obligations

CR Correction and Reversals

OA Other adjustments

PI Payor Initiated Reductions

PR Patient Responsibility

ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2430 • CASTECHNICAL REPORT • TYPE 3 LINE ADJUSTMENT

MAY 2006 481

REQUIRED CAS02 1034 Claim Adjustment Reason Code M 1 ID 1/5Code identifying the detailed reason the adjustment was made



REQUIRED CAS03 782 Monetary Amount M 1 R 1/18Monetary amount

SEMANTIC: CAS03 is the amount of adjustment.


SITUATIONAL CAS04 380 Quantity O 1 R 1/15Numeric value of quantity


744 SITUATIONAL RULE: Required when the number of service units has beenadjusted. If not required by this implementation guide, do not send.



SYNTAX: L050607, C0605, C0705

1045 SITUATIONAL RULE: Required when it is necessary to report an additionalnon-zero adjustment, beyond what has already been supplied, tothis service line for the Claim Adjustment Group Code reported inCAS01. If not required by this implementation guide, do not send.





SYNTAX: L050607, C0605





SYNTAX: L050607, C0705





482 MAY 2006


SYNTAX: L080910, C0908, C1008






SYNTAX: L080910, C0908





SYNTAX: L080910, C1008





SYNTAX: L111213, C1211, C1311






SYNTAX: L111213, C1211





MAY 2006 483


SYNTAX: L111213, C1311





SYNTAX: L141516, C1514, C1614






SYNTAX: L141516, C1514





SYNTAX: L141516, C1614





SYNTAX: L171819, C1817, C1917






484 MAY 2006


SYNTAX: L171819, C1817





SYNTAX: L171819, C1917





MAY 2006 485

DTPDATE OR TIME OR PERIOD 005010X223 • 837 • 2430 • DTPLINE CHECK OR REMITTANCE DATE

SEGMENT DETAIL

1046 DTP - LINE CHECK OR REMITTANCE DATEX12 Segment Name: Date or Time or Period



Segment Repeat: 1

Usage: REQUIRED

799 TR3 Example: DTP✽ 573✽ D8✽ 20040203~

DIAGRAM

DTP01 374 DTP02 1250 DTP03 1251



M 1 ID 3/3 M 1 ID 2/3 M 1 AN 1/35

ELEMENT DETAIL

USAGEREF.DES.




CODE DEFINITION

573 Date Claim PaidREQUIRED DTP02 1250 Date Time Period Format Qualifier M 1 ID 2/3



CODE DEFINITION



IMPLEMENTATION NAME: Adjudication or Payment Date

005010X223 • 837 • 2430 • DTP ASC X12N • INSURANCE SUBCOMMITTEELINE CHECK OR REMITTANCE DATE TECHNICAL REPORT • TYPE 3

486 MAY 2006

AMTMONETARY AMOUNT INFORMATION 005010X223 • 837 • 2430 • AMTREMAINING PATIENT LIABILITY

SEGMENT DETAIL

765 AMT - REMAINING PATIENT LIABILITYX12 Segment Name: Monetary Amount Information



Segment Repeat: 1

Usage: SITUATIONAL

1267 Situational Rule: Required when the Other Payer referenced in SVD01 of this iteration ofLoop ID-2430 has adjudicated this claim, provided line level information,and the provider has the ability to report line item information. If notrequired by this implementation guide, do not send.

1050 TR3 Notes: 1. In the judgment of the provider, this is the remaining amount to bepaid after adjudication by the Other Payer referenced in SVD01 of thisiteration of Loop ID-2430.

769 2. This segment is only used in provider submitted claims. It is not usedin Payer-to-Payer Coordination of Benefits (COB).

1270 3. This segment is not used if the claim level (Loop ID-2320) RemainingPatient Liability AMT segment is used for this Other Payer.

766 TR3 Example: AMT✽ EAF✽ 75~

DIAGRAM

AMT01 522 AMT02 782 AMT03 478



M 1 ID 1/3 M 1 R 1/18 O 1 ID 1/1

ELEMENT DETAIL

USAGEREF.DES.



CODE DEFINITION

EAF Amount OwedREQUIRED AMT02 782 Monetary Amount M 1 R 1/18

Monetary amount

IMPLEMENTATION NAME: Remaining Patient Liability


ASC X12N • INSURANCE SUBCOMMITTEE 005010X223 • 837 • 2430 • AMTTECHNICAL REPORT • TYPE 3 REMAINING PATIENT LIABILITY

MAY 2006 487

SETRANSACTION SET TRAILER 005010X223 • 837 • SETRANSACTION SET TRAILER

SEGMENT DETAIL

384 SE - TRANSACTION SET TRAILERX12 Segment Name: Transaction Set Trailer

X12 Purpose: To indicate the end of the transaction set and provide the count of thetransmitted segments (including the beginning (ST) and ending (SE) segments)

X12 Comments: 1. SE is the last segment of each transaction set.

Segment Repeat: 1

Usage: REQUIRED

385 TR3 Example: SE✽ 1230✽ 987654~

DIAGRAM

SE01 96 SE02 329

SE ✽ Number ofInc Segs ✽ TS Control

Number ~

M 1 N0 1/10 M 1 AN 4/9

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED SE01 96 Number of Included Segments M 1 N0 1/10Total number of segments included in a transaction set including ST and SEsegments

IMPLEMENTATION NAME: Transaction Segment Count

REQUIRED SE02 329 Transaction Set Control Number M 1 AN 4/9Identifying control number that must be unique within the transaction setfunctional group assigned by the originator for a transaction set

3 The Transaction Set Control Number in ST02 and SE02 must beidentical. The number must be unique within a specific interchange(ISA-IEA), but can repeat in other interchanges.

005010X223 • 837 • SE ASC X12N • INSURANCE SUBCOMMITTEETRANSACTION SET TRAILER TECHNICAL REPORT • TYPE 3

488 MAY 2006

3 Examples• Please visit http://www.wpc-edi.com/837 for additional or corrected

examples.

3.1 Institutional

3.1.1 Business Scenario 1 - 837 Institutional ClaimPatient is the same person as the Subscriber. The Primary Payer is Medicare and theSecondary payer is State Teachers. The bill is a 141 Type of Bill.

PRIMARY PAYER SUBSCRIBER: John T DoeSUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111SEX: MDOB: 11/11/1926MEDICARE INSURANCE ID#: 030005074APAYER ID #: 00435

PATIENT: Same as Primary Subscriber

DESTINATION PAYER: Medicare B

SUBMITTER: Jones HospitalEDI#: 12345

RECEIVER: MedicareEDI #: 00120

BILLING PROVIDER: Jones HospitalNPI: 9876540809TIN: 567891234MEDICARE PROVIDER: #330127ADDRESS: 225 Main Street Barkley Building, Centerville, PA 17111

ATTENDING PHYSICIAN: John J JonesUPIN #: B99937

PATIENT ACCOUNT NUMBER: 756048Q

489MAY 2006



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DATE OF ADMISSION: 09/11/96STATEMENT PERIOD DATE: 09/11/96 - 09/11/96PLACE OF SERVICE: Inpatient HospitalOccurrence Codes and Dates: A1 11/11/26 A2 11/01/91 B1 11/11/26 B2 01/01/87Condition Codes: 09Value Codes: A2 $15.31PRINCIPAL DIAGNOSIS CODE: 366.9SECONDARY DIAGNOSIS CODES: 401.9 794.31NUMBER OF COVERED DAYS: 1SERVICES:INSTITUTIONAL SERVICES RENDERED:REVENUE CODE: 0305 HCPCS Procedure Code: 85025 Unit: 1 Price $13.39REVENUE CODE: 0730 HCPCS Procedure Code: 93005 Unit: 1 Price: $76.54TOTAL CHARGES: $89.93

SECONDARY PAYER SUBSCRIBER: Jane S Doe (wife)SUBSCRIBER ADDRESS: 125 City Avenue, Centerville, PA 17111SEX: FDOB: 12/11/1927STATE TEACHERS ID#: 222004433PAYER ID #: 1135

LOOP SEGMENT/ELEMENT STRINGSEG #

TRANSACTION SET HEADER

ST*837*987654*005010X223~

1

BHT BEGINNING OF HIERARCHICAL TRANSACTION

BHT*0019*00*0123*19960918*0932*CH~

2

1000A SUBMITTER NAME

NM1 SUBMITTER NAME

NM1*41*2*JONES HOSPITAL*****46*12345~

3

MAY 2006490



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005010X292~

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PER SUBMITTER EDI CONTACT INFORMATION

PER*IC*JANE DOE*TE*9005555555~

4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*MEDICARE*****46*00120~

5

2000A BILLING PROVIDER

HL BILLING PROVIDER HIERARCHICAL LEVEL

HL*1**20*1~

6

PRV BILLING PROVIDER SPECIALTY

PRV*BI*PXC*203BA0200N~

7

2010AA BILLING PROVIDER NAME

NM1 BILLING PROVIDER NAME INCLUDING NATIONAL PROVIDER ID

NM1*85*2*JONES HOSPITAL*****XX*9876540809~

8

N3 BILLING PROVIDER ADDRESS

N3*225 MAIN STREET BARKLEY BUILDING~

9

N4 BILLING PROVIDER LOCATION

N4*CENTERVILLE*PA*17111~

10

REF BILLING PROVIDER TAX IDENTIFICATION NUMBER

REF*EI*567891234~

11


HL SUBSCRIBER HIERARCHICAL LEVEL

HL*2*1*22*0~

12

SBR SUBSCRIBER INFORMATION

SBR*P*18*******MB~

13

2010BA SUBSCRIBER NAME LOOP

NM1 SUBSCRIBER NAME

NM1*IL*1*DOE*JOHN*T***MI*030005074A~

14

N3 SUBSCRIBER ADDRESS

N3*125 CITY AVENUE~

15

491MAY 2006




N4 SUBSCRIBER LOCATION


16

DMG SUBSCRIBER DEMOGRAPHIC INFORMATION

DMG*D8*19261111*M~

17

2010BB PAYER NAME LOOP

NM1 PAYER NAME

NM1*PR*2*MEDICARE B*****PI*00435~

18

REF BILLING PROVIDER SECONDARY IDENTIFICATION

REF*G2*330127~

19

2300 CLAIM INFORMATION

CLM CLAIM LEVEL INFORMATION

CLM*756048Q*89.93***14:A:1*Y*A*Y*Y~

20

DTP STATEMENT DATES

DTP*434*D8*19960911~

21

CL1 INSTITUTIONAL CLAIM CODE

CL1*3**01~

22

HI PRINCIPAL DIAGNOSIS CODES

HI*BK:3669~

23

HI OTHER DIAGNOSIS INFORMATION

HI*BF:4019*BF:79431~

24

HI OCCURRENCE INFORMATION

HI*BH:A1:D8:19261111*BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~

25

HI VALUE INFORMATION

HI*BE:A2:::15.31~

26

HI CONDITION INFORMATION

HI*BG:09~

27

2310A ATTENDING PROVIDER NAME

NM1 ATTENDING PROVIDER

NM1*71*1*JONES*JOHN*J~

28

MAY 2006492



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CLM*756048Q*89.93***14:A:1*Y*A*Y*Y**********08~

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REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

REF*1G*B99937~

29


SBR OTHER SUBSCRIBER INFORMATION

SBR*S*01*351630*STATE TEACHERS*****CI~

30

DMG OTHER SUBSCRIBER DEMOGRAPHIC INFORMATION

DMG*D8*19271211*F~

31

OI OTHER INSURANCE COVERAGE INFORMATION

OI***Y***Y~

32


NM1 OTHER SUBSCRIBER NAME

NM1*IL*1*DOE*JANE*S***MI*222004433~

33

N3 - OTHER SUBSCRIBER ADDRESS

N3*125 CITY AVENUE~

34

N4 - OTHER SUBSCRIBER CITY, STATE, ZIP CODE


35

2330B OTHER PAYER NAME

NM1 OTHER PAYER NAME

NM1*PR*2*STATE TEACHERS*****PI*1135~

36

2400 SERVICE LINE

LX SERVICE LINE COUNTER

LX*1~

37

SV2 INSTITUTIONAL SERVICE

SV2*0305*HC:85025*13.39*UN*1~

38

DTP DATE - SERVICE DATES

DTP*472*D8*19960911~

39

2400 SERVICE LINE


LX*2~

40

493MAY 2006



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SV2*0730*HC:93005*76.54*UN*3~

41


DTP*472*D8*19960911~

42

TRAILER

SE TRANSACTION SET TRAILER

SE*43*987654~

43

Complete Data String:ST*837*987654*005010X223~BHT*0019*00*0123*19960918*0932*CH~N

M1*41*2*JONES HOSPITAL*****46*12345~PER*IC*JANE DOE*TE*90055

55555~NM1*40*2*MEDICARE*****46*00120~HL*1**20*1~PRV*BI*PXC*2

03BA0200N~NM1*85*2*JONES HOSPITAL*****XX*9876540809~N3*225 M

AIN STREET BARKLEY BUILDING~N4*CENTERVILLE*PA*17111~REF*EI*5

67891234~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*DOE*JOHN*T**

*MI*030005074A~N3*125 CITY AVENUE~N4*CENTERVILLE*PA*17111~DM

G*D8*19261111*M~NM1*PR*2*MEDICARE B*****PI*00435~REF*G2*3301

27~CLM*756048Q*89.93***14:A:1*Y*A*Y*Y~DTP*434*D8*19960911~CL

1*3**01~HI*BK:3669~HI*BF:4019*BF:79431~HI*BH:A1:D8:19261111*

BH:A2:D8:19911101*BH:B1:D8:19261111*BH:B2:D8:19870101~HI*BE:

A2:::15.31~HI*BG:09~NM1*71*1*JONES*JOHN*J~REF*1G*B99937~SBR*

S*01*351630*STATE TEACHERS*****CI~DMG*D8*19271211*F~OI***Y**

*Y~NM1*IL*1*DOE*JANE*S***MI*222004433~N3*125 CITY AVENUE~N4*

CENTERVILLE*PA*17111~NM1*PR*2*STATE TEACHERS*****PI*1135~LX*

1~SV2*0305*HC:85025*13.39*UN*1~DTP*472*D8*19960911~LX*2~SV2*

0730*HC:93005*76.54*UN*3~DTP*472*D8*19960911~SE*43*987654~

3.1.2 Business Scenario 2 - Two Claims for the SameProvider

For both claims the patient is the subscriber and the transaction is being directly submittedfrom the provider to the payer.

This example combines two claims for the same provider.

DESTINATION PAYER: TRICARE

MAY 2006494



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CLM*756048Q*89.93***14:A:1*Y*A*Y*Y**********08~

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33

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005010X292~

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PAYER ID: 99999BILLING PROVIDER: Jones HospitalBILLING PROVIDER ADDRESS: 225 MAIN STREET, ANYWHERE, PA, 17111BILLING PROVIDER SPECIALTY: 282N00000XBILLING PROVIDER EMPLOYER ID: 123456789BILLING PROVIDER NPI: 1234567890SUBMITTER ETIN: 12345SUBMITTER CONTACT: Jane DoeSUBMITTER CONTACT TELEPHONE: (111)222-3333

CLAIM #1:SUBSCRIBER: John T. DoeMEMBER ID: 030005074SUBSCRIBER ADDRESS: 125 City Avenue, Anywhere, PA, 17111DOB: November 11, 1968SEX: MPATIENT ACCOUNT #: 756048QCLAIM AMOUNT: 89.95TYPE OF BILL: 131CLAIM DATE: March 15, 2005PRINCIPAL DIAGNOSIS: 366.9OTHER DIAGNOSIS: 401.9, 794.31ATTENDING PHYSICIAN: John J. JonesATTENDING PHYSICIAN NPI: 1122334455UPIN: U12345PROCEDURES:Rev code: 0305 HCPCS: 85025 Billed Amt: 13.39 Units: 1.Rev code: 0730 HCPCS: 93010 Billed Amt: 76.56 Units: 3.

CLAIM #2:SUBSCRIBER: Joe SmithMEMBER ID: 123405074SUBSCRIBER ADDRESS: 5 Main Street, Anywhere, PA, 17111DOB: December 12, 1962SEX: MPATIENT ACCOUNT #: 756049QCLAIM AMOUNT: 50.00TYPE OF BILL: 131CLAIM DATE: April 1, 2005PRINCIPAL DIAGNOSIS: 300.00

495MAY 2006



ATTENDING PHYSICIAN: Judy J. JonesNPI: 9999999999PROVIDER SPECIALTY: 363LP0200NPROCEDURES:Rev code: 0300 HCPCS: 85087 Billed Amt: 50.00 Units: 1.



ST*837*987654*005010X223~

1


BHT*0019*00*0123*20050630*0932*CH~

2


NM1 SUBMITTER NAME

NM1*41*2*JONES HOSPITAL*****46*12345~

3


PER*IC*JANE DOE*TE*1112223333~

4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*TRICARE*****46*99999~

5



HL*1**20*1~

6


PRV*BI*PXC*282N00000X~

7



NM1*85*2*JONES HOSPITAL*****XX*1234567890~

8


N3*225 MAIN STREET~

9


N4*ANYWHERE*PA*17111~

10

MAY 2006496



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005010X292~



REF*EI*123456789~

11



HL*2*1*22*0~

12


SBR*P*18*******CH~

13


NM1 SUBSCRIBER NAME

NM1*IL*1*DOE*JOHN*T***MI*030005074~

14


N3*125 CITY AVENUE~

15



16


DMG*D8*19681111*M~

17


NM1 PAYER NAME

NM1*PR*2*TRICARE*****PI*99999~

18



CLM*756048Q*89.95***13:A:1*Y*C*Y*Y~

19

DTP STATEMENT DATES

DTP*434*RD8*20050315-20050315~

20


CL1***01~

21


HI*BK:3669~

22

497MAY 2006



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CLM*756048Q*89.95***13:A:1*Y*C*Y*Y**********08~



HI*BF:4019*BF:79431~

23



NM1*71*1*JONES*JOHN*J***XX*1122334455~

24

REF ATTENDING PROVIDER SECONDARY IDENTIFICATION

REF*1G*U12345~

25

2400 SERVICE LINE


LX*1~

26


SV2*0305*HC:85025*13.39*UN*1~

27


DTP*472*D8*20050315~

28

2400 SERVICE LINE


LX*2~

29


SV2*0730*HC:93010*76.56*UN*3~

30


DTP*472*D8*20050315~

31



HL*3*1*22*0~

32


SBR*P*18*******CH~

33


NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JOE****MI*123405074~

34

MAY 2006498



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N3*5 MAIN STREET~

35


N4*ANYWHERE*PA*17111~

36


DMG*D8*19621210*M~

37


NM1 PAYER NAME

NM1*PR*2*TRICARE*****PI*99999~

38



CLM*756049Q*50***13:A:1*Y*C*Y*Y~

39

DTP STATEMENT DATES

DTP*434*RD8*20050401-20050401~

40


CL1***01~

41


HI*BK:30000~

42



NM1*71*1*JONES*JUDY*J***XX*9999999999~

43

PRV - ATTENDING PROVIDER SPECIALTY INFORMATION

PRV*AT*PXC*363LP0200N~

44

2400 SERVICE LINE


LX*1~

45


SV2*0300*HC:85087*50*UN*1~

46

499MAY 2006



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CLM*756048Q*50***13:A:1*Y*C*Y*Y**********08~



DTP*472*D8*20050401~

47

TRAILER


SE*48*987654~

48


M1*41*2*JONES HOSPITAL*****46*12345~PER*IC*JANE DOE*TE*11122

23333~NM1*40*2*TRICARE*****46*99999~HL*1**20*1~PRV*BI*PXC*28

2N00000X~NM1*85*2*JONES HOSPITAL*****XX*1234567890~N3*225 MA

IN STREET~N4*ANYWHERE*PA*17111~REF*EI*123456789~HL*2*1*22*0~

SBR*P*18*******CH~NM1*IL*1*DOE*JOHN*T***MI*030005074~N3*125

CITY AVENUE~N4*ANYWHERE*PA*17111~DMG*D8*19681111*M~NM1*PR*2*

TRICARE*****PI*99999~CLM*756048Q*89.95***13:A:1*Y*C*Y*Y~DTP*

434*RD8*20050315-20050315~CL1***01~HI*BK:3669~HI*BF:4019*BF:

79431~NM1*71*1*JONES*JOHN*J***XX*1122334455~REF*1G*U12345~LX

*1~SV2*0305*HC:85025*13.39*UN*1~DTP*472*D8*20050315~LX*2~SV2

*0730*HC:93010*76.56*UN*3~DTP*472*D8*20050315~HL*3*1*22*0~SB

R*P*18*******CH~NM1*IL*1*SMITH*JOE****MI*123405074~N3*5 MAIN

STREET~N4*ANYWHERE*PA*17111~DMG*D8*19621210*M~NM1*PR*2*TRIC

ARE*****PI*99999~CLM*756049Q*50***13:A:1*Y*C*Y*Y~DTP*434*RD8

*20050401-20050401~CL1***01~HI*BK:30000~NM1*71*1*JONES*JUDY*

J***XX*9999999999~PRV*AT*PXC*363LP0200N~LX*1~SV2*0300*HC:850

87*50*UN*1~DTP*472*D8*20050401~SE*48*987654~

3.1.3 Business Scenario 3 - PPO Repriced ClaimRepriced claim being transmitted from a Regional PPO (Preferred Provider Organization)to a commercial health insurance company. The patient is a child of the subscriber. Inthis situation, the hospital has sent the claim to a clearinghouse, which then forwardedthe claim to the repricer; the claim has been repriced and is now being forwarded to theappropriate payer for payment.

SUBSCRIBER: Jenny JonesADDRESS: 4512 West Avenue, Evansville, AZ 863030000SEX: FDATE OF BIRTH: 07/31/1969

MAY 2006500



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46

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005010X292~

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45

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CLM*756048Q*89.95***13:A:1*Y*C*Y*Y**********08~

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CLM*756048Q*50***13:A:1*Y*C*Y*Y**********08~

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EMPLOYER: DESSERT COMPANY, INC.GROUP NUMBER: 46522567AWMEMBER ID: 345U8423H

PATIENT: Joy JonesADDRESS: 4512 West Avenue, Evansville, AZ 863030000SEX: FDATE OF BIRTH: 08/20/1998PATIENT ACCOUNT NUMBER: 456DFH43

OTHER INSURANCE: Other Coverage CompanyPAYER ID: 534524OTHER INSURED NAME: George JonesOTHER GROUP NAME: T&T Plumbing CompanyOTHER INSURED DATE OF BIRTH: 01/22/1970OTHER INSURED MEMBER ID: 56454566

SUBMITTER: Regional PPO NetworkSUBMITTER ID: 123456789TAX ID: 123456789

RECEIVER: Local Insurance CompanyRECEIVER ID: 54334452

DESTINATION PAYER: Local Insurance CompanyPAYER ID NUMBER: 7452723

BILLING PROVIDER: Good Health HospitalADDRESS: 592 North Elm Street, Edgewood, AZ 86001-5590NATIONAL PROVIDER ID (NPI): 1257234346TAX IDENTIFICATION NUMBER (TIN): 344-23-2321

ATTENDING PROVIDER: Simon JohnsonNATIONAL PROVIDER ID (NPI): 5544332211

TOTAL CLAIM CHARGES: $237.5TOTAL CLAIM REPRICED AMOUNT: $182.88TOTAL CLAIM SAVINGS AMOUNT: $54.62TIN FOR THE REPRICING ORGANIZATION: 332211445

SERVICE LINE 1 REPRICING INFORMATION:

501MAY 2006



TOTAL SERVICE LINE CHARGES: $178.00TOTAL REPRICED AMOUNT: $137.06SAVINGS AMOUNT: $40.94TIN FOR THE REPRICING ORGANIZATION: 332211445DATE OF SERVICE: 07/06/05

SERVICE LINE 2 REPRICING INFORMATION:TOTAL SERVICE LINE CHARGES: $59.50TOTAL REPRICED AMOUNT: $45.82SAVINGS AMOUNT: $13.68TIN FOR THE REPRICING ORGANIZATION: 332211445DATE OF SERVICE: 07/06/05



ST*837*1002*005010X223~

1


BHT*0019*00*1002*20050721*09460000*CH~

2


NM1 SUBMITTER NAME

NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~

3


PER*IC*SUBMITTER CONTACT INFO*TE*8001231234~

4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*LOCAL INSURANCE COMPANY*****46*54334452~

5



HL*1**20*1~

6



NM1*85*2*GOOD HEALTH HOSPITAL*****XX*1257234346~

7


N3*592 NORTH ELM STREET~

8

MAY 2006502



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005010X292~

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N4*EDGEWOOD*AZ*860015590~

9


REF*EI*344232321~

10



HL*2*1*22*1~

11


SBR*P**46522567AW******CI~

12


NM1 SUBSCRIBER NAME

NM1*IL*1*JONES*JENNY****MI*345U8423H~

13


N3*4512 WEST AVENUE~

14


N4*EVANSVILLE*AZ*863030000~

15


DMG*D8*19690731*F~

16


NM1 PAYER NAME

NM1*PR*2*LOCAL INSURANCE COMPANY*****PI*7452723~

17


HL PATIENT HIERARCHICAL LEVEL

HL*3*2*23*0~

18

PAT PATIENT INFORMATION

PAT*19~

19

2010CA PATIENT NAME

NM1 PATIENT NAME

NM1*QC*1*JONES*JOY~

20

503MAY 2006




N3 PATIENT STREET ADDRESS

N3*4512 WEST AVENUE~

21

N4 PATIENT LOCATION

N4*EVANSVILLE*AZ*863030000~

22

DMG PATIENT DEMOGRAPHIC INFORMATION

DMG*D8*19980820*F~

23



CLM*456DFH43*237.5***13>A>1*Y**Y*Y~

24

DTP STATEMENT DATES

DTP*434*RD8*20050706-20050706~

25

DTP ADMISSION DATE/HOUR

DTP*435*DT*200507060800~

26


CL1**2*01~

27

AMT PATIENT ESTIMATED AMOUNT DUE

AMT*F3*237.5~

28

REF REPRICED CLAIM NUMBER

REF*9A*09459034092~

29

REF CLEARING HOUSE CLAIM NUMBER (ASSIGNED BY THE CLEARING HOUSE WHEN

TRANSMITTING TO THE REPRICER)

REF*D9*04566877634343456~

30

HI HEALTH CARE PRINCIPAL DIAGNOSIS CODES

HI*BK>38181~

31


HI*BF>38900~

32

HI OCCURRENCE INFORMATION

HI*BH>11>D8>20050706~

33

MAY 2006504



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CLM*456DFH43*237.5***13>A>1*Y**Y*Y**********08~

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HCP HEALTH CARE PRICING - REPRICING INFORMATION

HCP*03*182.88*54.62*123456789~

34



NM1*71*1*JOHNSON*SIMON****XX*5544332211~

35



SBR*S*19**T&T PLUMBING COMPANY*****CI~

36


DMG*D8*19700122*M~

37


OI***Y***Y~

38



NM1*IL*1*JONES*GEORGE****MI*56454566~

39



NM1*PR*2*OTHER COVERAGE COMPANY*****PI*534524~

40

2400 SERVICE LINE


LX*1~

41


SV2*0471*HC>92557*178*UN*1~

42


DTP*472*D8*20050706~

43


HCP*03*137.06*40.94~

44

2400 SERVICE LINE


LX*2~

45

505MAY 2006



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SV2*0471*HC>92567*59.5*UN*1~

46


DTP*472*D8*20050706~

47


HCP*03*45.82*13.68~

48

TRAILER


SE*49*1002~

49

Complete Data String:ST*837*1002*005010X223~BHT*0019*00*1002*20050721*09460000*CH

~NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~PER*IC*SUBMI

TTER CONTACT INFO*TE*8001231234~NM1*40*2*LOCAL INSURANCE COM

PANY*****46*54334452~HL*1**20*1~NM1*85*2*GOOD HEALTH HOSPITA

L*****XX*1257234346~N3*592 NORTH ELM STREET~N4*EDGEWOOD*AZ*8

60015590~REF*EI*344232321~HL*2*1*22*1~SBR*P**46522567AW*****

*CI~NM1*IL*1*JONES*JENNY****MI*345U8423H~N3*4512 WEST AVENUE

~N4*EVANSVILLE*AZ*863030000~DMG*D8*19690731*F~NM1*PR*2*LOCAL

INSURANCE COMPANY*****PI*7452723~HL*3*2*23*0~PAT*19~NM1*QC*1

*JONES*JOY~N3*4512 WEST AVENUE~N4*EVANSVILLE*AZ*863030000~DM

G*D8*19980820*F~CLM*456DFH43*237.5***13>A>1*Y**Y*Y~DTP*434*R

D8*20050706-20050706~DTP*435*DT*200507060800~CL1**2*01~AMT*F

3*237.5~REF*9A*09459034092~REF*D9*04566877634343456~HI*BK>38

181~HI*BF>38900~HI*BH>11>D8>20050706~HCP*03*182.88*54.62*123

456789~NM1*71*1*JOHNSON*SIMON****XX*5544332211~SBR*S*19**T&T

PLUMBING COMPANY*****CI~DMG*D8*19700122*M~OI***Y***Y~NM1*IL*

1*JONES*GEORGE****MI*56454566~NM1*PR*2*OTHER COVERAGE COMPAN

Y*****PI*534524~LX*1~SV2*0471*HC>92557*178*UN*1~DTP*472*D8*2

0050706~HCP*03*137.06*40.94~LX*2~SV2*0471*HC>92567*59.5*UN*1

~DTP*472*D8*20050706~HCP*03*45.82*13.68~SE*49*1002~

MAY 2006506



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CLM*456DFH43*237.5***13>A>1*Y**Y*Y**********08~

3.1.4 Business Scenario 4 - Out of Network RepricedClaim

An out of network claim is being transmitted from a Regional PPO (Preferred ProviderOrganization) to a commercial health insurance company.The patient and the subscriberare the same. In this situation, the hospital has sent the claim to a clearinghouse, whichthen forwarded the claim to the repricer; the claim has been determined to be out ofnetwork and is now being forwarded to the appropriate payer for payment.

PATIENT/SUBSCRIBER: JAMES A SMITHADDRESS: 934 North Street, Columbus, OH 432150000SEX: MDATE OF BIRTH: 10/15/1962EMPLOYER: TREE TRIMMING SERVICEGROUP NUMBER: 34561WMEMBER ID: 34902390FPATIENT CONTROL NUMBER: W392-49141

SUBMITTER: Regional PPO NetworkSUBMITTER ID: 123456789

RECEIVER: Conservative InsuranceRECEIVER ID: 000110002

DESTINATION PAYER: Conservative InsurancePAYER ID NUMBER: 00123

BILLING PROVIDER: LOCAL HOSPITALADDRESS: 3423 Small Street, Columbus, OH 432150000NATIONAL PROVIDER ID (NPI): 1122334455TAX IDENTIFICATION NUMBER (TIN): 111-00-2222

RENDERING PROVIDER: Dawn RiversNATIONAL PROVIDER ID (NPI): 2244224455

REPRICING INFORMATION:TOTAL CHARGES: $14.84TOTAL REPRICED AMOUNT: $0SAVINGS AMOUNT: $0TIN FOR THE REPRICING ORGANIZATION: 333001234DATE OF SERVICE: 06/17/05

507MAY 2006





ST*837*1024*005010X223~

1


BHT*0019*00*1024*20050711*1335*CH~

2


NM1 SUBMITTER NAME


3



4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~

5



HL*1**20*1~

6



NM1*85*2*LOCAL HOSPITAL*****XX*1122334455~

7


N3*3423 SMALL STREET~

8


N4*COLUMBUS*OH*432150000~

9


REF*EI*111002222~

10



HL*2*1*22*0~

11


SBR*P*18*34561W******CI~

12

MAY 2006508



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NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JAMES*A***MI*34902390F~

13


N3*934 NORTH STREET~

14


N4*COLUMBUS*OH*432150000~

15


DMG*D8*19621015*M~

16

2010BB - PAYER NAME LOOP

NM1 PAYER NAME

NM1*PR*2*CONSERVATIVE INSURANCE*****PI*0012~

17



CLM*W392-49141*14.84***13>A>1*Y**Y*Y~

18

DTP STATEMENT DATES

DTP*434*RD8*20050617-20050617~

19

DTP ADMISSION DATE/HOUR

DTP*435*DT*200506170800~

20


CL1**1*01~

21

AMT PATIENT ESTIMATED AMOUNT DUE

AMT*F3*14.84~

22


REF*9A*459804390823~

23



REF*D9*32423466233~

24

509MAY 2006



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CLM*W392-49141*14.84***13>A>1*Y**Y*Y**********08~

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HI HEALTH CARE DIAGNOSIS CODES

HI*BK>53081~

25

HCP HEALTH CARE PRICING - OUT OF NETWORK INFORMATION

HCP*00*0**333001234*********T1~

26



NM1*71*1*RIVERS*DAWN****XX*2244224455~

27

2400 SERVICE LINE


LX*1~

28


SV2*0301*HC>82270*14.84*UN*1~

29


DTP*472*D8*20050617~

30

TRAILER


SE*31*1024~

31

Complete Data String:ST*837*1024*005010X223~BHT*0019*00*1024*20050711*1335*CH~NM1

*41*2*REGIONAL PPO NETWORK*****46*123456789~PER*IC*SUBMITTER

CONTACT INFO*TE*8001231234~NM1*40*2*CONSERVATIVE INSURANCE**

***46*000110002~HL*1**20*1~NM1*85*2*LOCAL HOSPITAL*****XX*11

22334455~N3*3423 SMALL STREET~N4*COLUMBUS*OH*432150000~REF*E

I*111002222~HL*2*1*22*0~SBR*P*18*34561W******CI~NM1*IL*1*SMI

TH*JAMES*A***MI*34902390F~N3*934 NORTH STREET~N4*COLUMBUS*OH

*432150000~DMG*D8*19621015*M~NM1*PR*2*CONSERVATIVE INSURANCE

*****PI*00123~CLM*W392-49141*14.84***13>A>1*Y**Y*Y~DTP*434*R

D8*20050617-20050617~DTP*435*DT*200506170800~CL1**1*01~AMT*F

3*14.84~REF*9A*459804390823~REF*D9*32423466233~HI*BK>53081~H

CP*00*0**333001234*********T1~NM1*71*1*RIVERS*DAWN****XX*224

4224455~LX*1~SV2*0301*HC>82270*14.84*UN*1~DTP*472*D8*2005061

7~SE*31*1024~

MAY 2006510



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3.2 Property and CasualtyHealthcare Bill to Property & Casualty PayerThe requirements for submitting of Healthcare bills to Property & Casualty payers arepresented here.

837 Transaction SetHealthcare bills can be submitted to a Property & Casualty (P&C) payer. Becausecoverage is triggered by a specific event, certain information is critical to the billingprocess.

P&C bills must include both the bill information as well as the information related to theevent that caused the injury or illness. Information concerning the event is necessary toassociate a bill with the P&C claim.

P &C insurance is governed by State Insurance Regulations, Departments of Labor,Worker’s Compensation Boards, or other jurisdictionally defined entities, which oftenmandates compliance with Jurisdiction-specific procedures.

The Business Need: Provider to P&C Payer Bill Transmission

• The date of accident/occurrence/onset of symptoms (Date of Loss) is a critical pieceof information and must always be transmitted in the "Date - Accident" DTP segmentwithin Loop ID-2300 (Claim loop).

The Date of Loss is used to determine the eligibility of coverage.• The unique identification number, referred to in P&C as a claim number, must be

provided. The claim number is transmitted in the REF segment of Loop ID-2010BA ifthe patient is the subscriber or in the REF segment of Loop ID-2010CA if the patientis not the subscriber.

Without a date of loss on the bill and claim number, the bill will incomplete and may berejected.

3.2.1 Business Scenario 1 - Automobile AccidentCLAIM TYPE: AUTOMOBILE ACCIDENTTYPE OF BILL: HOSPITALPRIMARY PAYER: PROPERTY & CASUALTY INSURER

511MAY 2006



THE PATIENT IS A DIFFERENT PERSON THAN THE SUBSCRIBER. THE PAYER ISA COMMERCIAL PROPERTY & CASUALTY INSURANCE COMPANY.

DATE OF ACCIDENT: 10/31/2005SUBSCRIBER: HAL HOWLINGSUBSCRIBER ADDRESS: 327 BRONCO DRIVE, GETAWAY, CA, 99999POLICY NUMBER: B999-777-91GINSURANCE COMPANY: HEISMAN INSURANCE COMPANYCLAIM NUMBER: 32-3232-32

PATIENT: RON MEXICOPATIENT ADDRESS: 32 BUFFALO RUN, ROCKING HORSE, CA, 99666SEX: MDOB: 06/01/48

DESTINATION PAYER/RECEIVER: HEISMAN INSURANCE COMPANYPAYER ADDRESS: 1 TROPHY LANE, NY, NY, 10032PAYER ID: 999888777

BILLING PROVIDER/SENDER: HALL OF FAME MEMORIAL HOSPITALTIN: 737373737NATIONAL PROVIDER IDENTIFIER: 2365259638ADDRESS: 1 CANTON ROAD, BROKEN FIELD, CA, 99998

PAY-TO-PROVIDER: HALL OF FAME MEMORIAL HOSPITAL

ATTENDING PROVIDER: VINCENT LOMBARDO, MD

PATIENT ACCOUNT NUMBER: 000-00-0032CASE: THE PATIENT WAS A PASSENGER IN THE SUBSCRIBER’S AUTOMOBILE,AND THE PATIENT REPORTS THAT HIS HAND WAS CUT WHEN THE CAR WASSTRUCK IN THE REAR.

DIAGNOSIS: 884.2, E975.0, E986.0

SERVICES RENDERED: OUTPATIENT E/R VISIT, LACERATION REPAIR, HISTOLOGYTESTDOS = 10/31/2005, POS = E/R, TOS = OUTPATIENTCHARGES: E/R ROOM = $150.00, LACERATION REPAIR = $75.00, DNA TEST =$100.00, E/R ATTENDING PHYSICIAN = $220.00. TOTAL CHARGES = $545.00.

MAY 2006512




HEADER

ST TRANSACTION SET HEADER

ST*837*557766*005010X223~

1


BHT*0019*00*0324*20051111*1800*CH~

2

1000A SUBMITTER

NM1 SUBMITTER NAME

NM1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~

3


PER*IC*KATE CASEY*TE*7152569877~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~

5

2000A BILLING PROVIDER HL LOOP

HL*1**20*1~

6


PRV*BI*PXC*203BA0200N~

7

NM1 BILLING PROVIDER NAME

NM1*85*2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~

8


N3*1 CANTON ROAD~

9


N4*BROKEN FIELD*CA*99998~

10


REF*EI*737373737~

11


HL*2*1*22*1~

12


SBR*P********AM~

13

513MAY 2006



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2010BA SUBSCRIBER

NM1*IL*1*HOWLING*HAL****MI*B999777791G~

14

2010BB PAYER

NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~

15


HL*3*2*23*0~

16


PAT*21~

17

NM1 PATIENT NAME

NM1*QC*1*MEXICO*RON~

18

N3 PATIENT ADDRESS

N3*32 BUFFALO RUN~

19

N4 PATIENT CITY/STATE/ZIP CODE

N4*ROCKING HORSE*CA*99666~

20


DMG*D8*19480601*M~

21

REF PROPERTY AND CASUALTY CLAIM NUMBER

REF*Y4*32323232~

22

2300 CLAIM

CLM*67236695521*545***13:A:1*Y*A*Y*Y~

23

DTP STATEMENT DATES

DTP*434*RD8*20051031-20051101~

24


CL1*3*7*1~

25

REF AUTO ACCIDENT STATE

REF*LU*CA~

26

HI PRINCIPLE DIAGNOIS

HI*BK:8842~

27

MAY 2006514



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HI PATIENT’S REASON FOR VISIT

HI*PR:8842~

28

HI EXTERNAL CAUSE OF INJURY

HI*BN:E9750*BN:E9860~

29


NM1 ATTENDING PROVIDER NAME

NM1*71*1*LOMBARDO*VINCENT****XX*2533698543~

30

2400 SERVICE LINE NUMBER

LX SERVICE LINE NUMBER

LX*1~

31

SV2 INSTITUTIONAL SERVICE LINE

SV2*0450*HC:98765*150*UN*1~

32

DTP DATE - SERVICE DATE

DTP*472*D8*20051031~

33


LX*2~

34


SV2*0360*HC:26591*75*UN*1~

35


DTP*472*D8*20051031~

36


LX*3~

37


SV2*0312*HC:86225*100*UN*2~

38


DTP*472*D8*20051031~

39


LX*4~

40

515MAY 2006



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SV2*0360*HC:99283*220*UN*1~

41


DTP*472*D8*20051031~

42

TRAILER

SE - TRANSACTION SET TRAILER

SE*43*557766~

43


M1*41*2*HALL OF FAME MEMORIAL HOSPITAL*****46*737373737~PER*

IC*kate casey*TE*7152569877~NM1*40*2*HEISMAN INSURANCE COMPA

NY*****46*999888777~HL*1**20*1~PRV*BI*pxc*203BA0200N~NM1*85*

2*HALL OF FAME MEMORIAL HOSPITAL*****XX*2365259638~N3*1 CANT

ON ROAD~N4*BROKEN FIELD*CA*99998~REF*EI*737373737~HL*2*1*22*

1~SBR*P********AM~NM1*IL*1*HOWLING*HAL****MI*B999777791G~NM1

*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~HL*3*2*23*0

~PAT*21~NM1*QC*1*MEXICO*RON~N3*32 BUFFALO RUN~N4*ROCKING HOR

SE*CA*99666~DMG*D8*19480601*M~REF*Y4*32323232~CLM*6723669552

1*545***13:A:1*Y*A*Y*Y~DTP*434*RD8*20051031-20051101~CL1*3*7

*1~REF*LU*CA~HI*BK:8842~HI*PR:8842~HI*BN:E9750*BN:E9860~NM1*

71*1*LOMBARDO*VINCENT****XX*2533698543~LX*1~SV2*0450*HC:9876

5*150*UN*1~DTP*472*D8*20051031~LX*2~SV2*0360*HC:26591*75*UN*

1~DTP*472*D8*20051031~LX*3~SV2*0312*HC:86225*100*UN*2~DTP*47

2*D8*20051031~LX*4~SV2*0360*HC:99283*220*UN*1~DTP*472*D8*200

51031~SE*43*557766~

MAY 2006516



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A External Code Sources

A.1 External Code Sources

5 Countries, Currencies and Funds

SIMPLE DATA ELEMENT/CODE REFERENCES26, 100, 1715, 66/38, 235/CH, 955/SP

SOURCECodes for Representation of Names of Countries, ISO 3166-(Latest Release)

Codes for Representation of Currencies and Funds, ISO 4217-(Latest Release)

AVAILABLE FROMAmerican National Standards Institute25 West 43rd Street, 4th FloorNew York, NY 10036

ABSTRACTPart 1 (Country codes) of the ISO 3166 international standard establishes codes thatrepresent the current names of countries, dependencies, and other areas of specialgeopolitical interest, on the basis of lists of country names obtained from the UnitedNations. Part 2 (Country subdivision codes) establishes a code that represents thenames of the principal administrative divisions, or similar areas, of the countries, etc.included in Part 1. Part 3 (Codes for formerly used names of countries) establishes acode that represents non-current country names, i.e., the country names deleted fromISO 3166 since its first publication in 1974. Most currencies are those of the geopoliticalentities that are listed in ISO 3166 Part 1, Codes for the Representation of Names ofCountries. The code may be a three-character alphabetic or three-digit numeric. Thetwo leftmost characters of the alphabetic code identify the currency authority to whichthe code is assigned (using the two character alphabetic code from ISO 3166 Part 1, ifapplicable). The rightmost character is a mnemonic derived from the name of the majorcurrency unit or fund. For currencies not associated with a single geographic entity, aspecially-allocated two-character alphabetic code, in the range XA to XZ identifies thecurrency authority. The rightmost character is derived from the name of the geographicarea concerned, and is mnemonic to the extent possible.The numeric codes are identicalto those assigned to the geographic entities listed in ISO 3166 Part 1.The range 950-998

A.1MAY 2006



is reserved for identification of funds and currencies not associated with a single entitylisted in ISO 3166 Part 1.

22 States and Provinces

SIMPLE DATA ELEMENT/CODE REFERENCES156, 66/SJ, 235/A5, 771/009

SOURCEU.S. Postal Service or

Canada Post orBureau of Transportation Statistics

AVAILABLE FROMThe U.S. state codes may be obtained from:U.S. Postal ServiceNational Information Data CenterP.O. Box 2977Washington, DC 20013www.usps.govThe Canadian province codes may be obtained from:http://www.canadapost.caThe Mexican state codes may be obtained from:www.bts.gov/ntda/tbscd/mex-states.html

ABSTRACTProvides names, abbreviations, and two character codes for the states, provinces andsub-country divisions as defined by the appropriate government agency of the UnitedStates, Canada, and Mexico.

51 ZIP Code

SIMPLE DATA ELEMENT/CODE REFERENCES116, 66/16, 309/PQ, 309/PR, 309/PS, 771/010

SOURCENational ZIP Code and Post Office Directory, Publication 65

The USPS Domestic Mail Manual

MAY 2006A.2



AVAILABLE FROMU.S Postal ServiceWashington, DC 20260New OrdersSuperintendent of DocumentsP.O. Box 371954Pittsburgh, PA 15250-7954

ABSTRACTThe ZIP Code is a geographic identifier of areas within the United States and its territoriesfor purposes of expediting mail distribution by the U.S. Postal Service. It is five or ninenumeric digits. The ZIP Code structure divides the U.S. into ten large groups of states.The leftmost digit identifies one of these groups. The next two digits identify a smallergeographic area within the large group. The two rightmost digits identify a local deliveryarea. In the nine-digit ZIP Code, the four digits that follow the hyphen further subdividethe delivery area. The two leftmost digits identify a sector which may consist of severallarge buildings, blocks or groups of streets. The rightmost digits divide the sector intosegments such as a street, a block, a floor of a building, or a cluster of mailboxes. TheUSPS Domestics Mail Manual includes information on the use of the new 11-digit zipcode.

130 Healthcare Common Procedural Coding System

SIMPLE DATA ELEMENT/CODE REFERENCES235/HC, 1270/BO, 1270/BP

SOURCEHealthcare Common Procedural Coding System

AVAILABLE FROMCenters for Medicare & Medicaid Services7500 Security BoulevardBaltimore, MD 21244

ABSTRACTHCPCS is Centers for Medicare & Medicaid Service's (CMS) coding scheme to groupprocedures performed for payment to providers.

A.3MAY 2006



131 International Classification of Diseases, 9th Revision,Clinical Modification (ICD-9-CM)

SIMPLE DATA ELEMENT/CODE REFERENCES128/ICD, 235/DX, 235/ID, 1270/BF, 1270/BJ, 1270/BK, 1270/BN, 1270/BQ, 1270/BR,1270/DD, 1270/PR, 1270/SD, 1270/TD, 1270/AAU, 1270/AAV, 1270/AAX

SOURCEInternational Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM),Volumes I, II and III

AVAILABLE FROMSuperintendent of DocumentsU.S. Government Printing OfficeP.O. Box 371954Pittsburgh, PA 15250

ABSTRACTThe International Classification of Diseases, 9th Revision, Clinical Modification(ICD-9-CM), Volumes I, II (diagnoses) and III (procedures) describes the classificationof morbidity and mortality information for statistical purposes and for the indexing ofhealthcare records by diseases and procedures.

132 National Uniform Billing Committee (NUBC) Codes

SIMPLE DATA ELEMENT/CODE REFERENCES235/NU, 235/RB, 1270/BE, 1270/BG, 1270/BH, 1270/BI, 1270/NUB

SOURCENational Uniform Billing Data Element Specifications

AVAILABLE FROMNational Uniform Billing CommitteeAmerican Hospital AssociationOne North FranklinChicago, IL 60606

ABSTRACTRevenue codes are a classification of hospital charges in a standard grouping that iscontrolled by the National Uniform Billing Committee.

MAY 2006A.4



139 Claim Adjustment Reason Code

SIMPLE DATA ELEMENT/CODE REFERENCES1034

SOURCENational Health Care Claim Payment/Advice Committee Bulletins

AVAILABLE FROMBlue Cross/Blue Shield AssociationInterplan Teleprocessing Services Division676 N. St. Clair StreetChicago, IL 60611

ABSTRACTBulletins describe standard codes and messages that detail the reason why an adjustmentwas made to a health care claim payment by the payer.

229 Diagnosis Related Group Number (DRG)

SIMPLE DATA ELEMENT/CODE REFERENCES1354, 1270/DR

SOURCEFederal Register and Health Insurance Manual 15 (HIM 15)

AVAILABLE FROMSuperintendent of DocumentsU.S. Government Printing OfficeWashington, DC 20402

ABSTRACTA patient classification scheme that clusters patients into categories on the basis ofpatient's illness, diseases, and medical problems.

230 Admission Source Code


A.5MAY 2006





ABSTRACTA variety of codes explaining who recommended admission to a medical facility.

231 Admission Type Code




ABSTRACTA variety of codes explaining the priority of the admission to a medical facility.

235 Claim Frequency Type Code


SOURCENational Uniform Billing Data Element Specifications Type of Bill Position 3

AVAILABLE FROMNational Uniform Billing CommitteeAmerican Hospital AssociationOne North Franklin

MAY 2006A.6



Chicago, IL 60606

ABSTRACTA variety of codes explaining the frequency of the bill submission.

236 Uniform Billing Claim Form Bill Type

SIMPLE DATA ELEMENT/CODE REFERENCES1332/A

SOURCENational Uniform Billing Data Element Specifications Type of Bill Positions 1 and 2


ABSTRACTA variety of codes describing the type of medical facility.

239 Patient Status Code




ABSTRACTA variety of codes indicating patient status as of the statement covers through date.

A.7MAY 2006



240 National Drug Code by Format

SIMPLE DATA ELEMENT/CODE REFERENCES235/N1, 235/N2, 235/N3, 235/N4, 235/N5, 235/N6, 1270/NDC

SOURCEDrug Establishment Registration and Listing Instruction Booklet

AVAILABLE FROMFederal Drug Listing Branch HFN-3155600 Fishers LaneRockville, MD 20857

ABSTRACTPublication includes manufacturing and labeling information as well as drug packagingsizes.

245 National Association of Insurance Commissioners (NAIC)Code

SIMPLE DATA ELEMENT/CODE REFERENCES128/NF

SOURCENational Association of Insurance Commissioners Company Code List Manual

AVAILABLE FROMNational Association of Insurance Commission Publications Department12th Street, Suite 1100Kansas City, MO 64105-1925

ABSTRACTCodes that uniquely identify each insurance company.

359 Treatment Codes

SIMPLE DATA ELEMENT/CODE REFERENCES235/TD, 1270/TC

MAY 2006A.8



SOURCEHealth Care Financing Administration Treatment Codes

AVAILABLE FROMCenters for Medicare and Medicaid Services Office of Financial ManagementProgram Integrity GroupC3-02-167500 Security Blvd.Baltimore, MD 21244-1850

ABSTRACTCodes used to describe the treatments provided in a home health setting.

411 Remittance Advice Remark Codes

SIMPLE DATA ELEMENT/CODE REFERENCES1270/HE

SOURCECenters for Medicare and Medicaid Services

OIS/BSOG/DDIS,Mail stop N2-13-167500 Security BoulevardBaltimore, MD 21244

AVAILABLE FROMWashington Publishing Companyhttp://www.wpc-edi.com/

ABSTRACTRemittance Advice Remark Codes (RARC) are used to convey information about claimadjudication. It could provide general information or supplemental explanations to anadjustment already reported by a Claim Adjustment Reason Code.

513 Home Infusion EDI Coalition (HIEC) Product/Service CodeList

SIMPLE DATA ELEMENT/CODE REFERENCES235/IV, 1270/HO

A.9MAY 2006



SOURCEHome Infusion EDI Coalition (HIEC) Coding System

AVAILABLE FROMHIEC ChairpersonHIBCC (Health Industry Business Communications Council)5110 North 40th StreetSuite 250Phoenix, AZ 85018

ABSTRACTThis list contains codes identifying home infusion therapy products/services.

537 Centers for Medicare and Medicaid Services NationalProvider Identifier

SIMPLE DATA ELEMENT/CODE REFERENCES66/XX, 128/HPI

SOURCENational Provider System

AVAILABLE FROMCenters for Medicare and Medicaid ServicesOffice of Financial ManagementDivision of Provider/Supplier EnrollmentC4-10-077500 Security BoulevardBaltimore, MD 21244-1850

ABSTRACTThe Centers for Medicare and Medicaid Services is developing the National ProviderIdentifier (NPI), which has been proposed as the standard unique identifier for eachhealth care provider under the Health Insurance Portability and Accountability Act of1996.

540 Centers for Medicare and Medicaid Services PlanID

SIMPLE DATA ELEMENT/CODE REFERENCES66/XV, 128/ABY

MAY 2006A.10



SOURCEPlanID Database

AVAILABLE FROMCenters for Medicare and Medicaid ServicesCenter of Beneficiary Services, Membership Operations GroupDivision of Benefit CoordinationS1-05-067500 Security BoulevardBaltimore, MD 21244-1850

ABSTRACTThe Centers for Medicare and Medicaid Services has joined with other payers to developa unique national payer identification number. The Centers for Medicare and MedicaidServices is the authorizing agent for enumerating payers through the services of a PlanIDRegistrar. It may also be used by other payers on a voluntary basis.

576 Workers Compensation Specific Procedure and SupplyCodes

SIMPLE DATA ELEMENT/CODE REFERENCES235/ER

SOURCEIAIABC Jurisdiction Medical Bill Report Implementation Guide

AVAILABLE FROMIAIABC EDI Implementation ManagerInternational Association of Industrial Accident Boards and Commissions8643 Hauses - Suite 20087th ParkwayShawnee Mission, KS 66215

ABSTRACTThe IAIABC Jurisdiction Medical Bill Report Implementation Guide describes therequirements for submitting and the data contained within a jurisdiction medical report.The Implementation Guide includes: Reporting scenarios, data definitions, trading partnerrequirements tables, reference to industry codes, and IAIABC maintained code lists.

A.11MAY 2006



682 Health Care Provider Taxonomy

SIMPLE DATA ELEMENT/CODE REFERENCES128/PXC, 1270/68

SOURCEThe National Uniform Claim Committee

AVAILABLE FROMThe National Uniform Claim Committeec/o American Medical Association515 North State StreetChicago, IL 60610

ABSTRACTCodes defining the health care service provider type, classification, and area ofspecialization.

716 Health Insurance Prospective Payment System (HIPPS) RateCode for Skilled Nursing Facilities

SIMPLE DATA ELEMENT/CODE REFERENCES235/HP

SOURCEHealth Insurance Prospective Payment System (HIPPS) Rate Code for Skilled NursingFacilities

AVAILABLE FROMDivision of Institutional Claims ProcessingCenters for Medicare and Medicaid ServicesC4-10-077500 Security BoulevardBaltimore, MD 21244-1850

ABSTRACTThe Centers for Medicare and Medicaid services develops and publishes the HIPPScodes to establish a coding system for claims submission and claims payment underprospective payment systems.These codes represent the case mix classification groupsthat are used to determine payment rates under prospective payment systems. Case

MAY 2006A.12



mix classification groups include, but may not be limited to , resource utilization groups(RUGs) for skilled nursing facilities, home health resource groups (HHRGs) for homehealth agencies, and case mix groups (CMGs) for inpatient rehabilitation facilities.

843 Advanced Billing Concepts (ABC) Codes

SIMPLE DATA ELEMENT/CODE REFERENCES235/WK, 1270/CAH

SOURCEThe CAM and Nursing Coding Manual

AVAILABLE FROMAlternative Link6121 Indian School Road NESuite 131Albuquerque, NM 87110

ABSTRACTThe manual contains the Advanced Billing Concepts (ABC) codes, descriptive termsand identifiers for reporting complementary or alternative medicine, nursing, and otherintegrative health care procedures.

896 International Classification of Diseases, 10th Revision,Procedure Coding System (ICD-10-PCS)

SIMPLE DATA ELEMENT/CODE REFERENCES235/IP, 1270/BBQ, 1270/BBR

SOURCEInternational Classification of Diseases, 10th Revision, Procedure Coding System(ICD-10-PCS)

AVAILABLE FROMCMM, HAPG, Division of Acute CareCenters for Medicare and Medicaid Services7500 Security BoulevardBaltimore, MD 21244

A.13MAY 2006



ABSTRACTThe International Classification of Diseases, 10th Revision, Procedure Coding System(ICD-10-PCS), describes the classification of inpatient procedures for statistical purposesand for the indexing of healthcare records by procedures.

897 International Classification of Diseases, 10th Revision,Clinical Modification (ICD-10-CM)

SIMPLE DATA ELEMENT/CODE REFERENCES235/DC, 1270/ABF, 1270/ABJ, 1270/ABK, 1270/ABN, 1270/ABU, 1270/ABV, 1270/ADD,1270/APR, 1270/ASD, 1270/ATD

SOURCEInternational Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM)

AVAILABLE FROMOCD/Classifications and Public Health Data StandardsNational Center for Health Statistics3311 Toledo RoadHyattsville, MD 20782

ABSTRACTThe International Classicication of Diseases, 10th Revision, Clinical Modification(ICD-10-CM), describes the classification of morbidity and mortality information forstatistical purposes and for the indexing of healthcare records by diseases.

932 Universal Postal Codes


SOURCEUniversal Postal Union website

AVAILABLE FROMInternational Bureau of the Universal Postal UnionPOST*CODECase postale 133000 BERNE 15 Switzerland

MAY 2006A.14



ABSTRACTThe postcode is the fundamental, essential element of an address. A unique, universalidentifier, it unambiguously identifies the addressee's locality and assists in thetransmission and sorting of mail items. At present, 105 UPU member countries usepostcodes as part of their addressing systems.

A.15MAY 2006



B Nomenclature

B.1 ASC X12 Nomenclature

B.1.1 Interchange and Application Control StructuresAppendix B is provided as a reference to the X12 syntax, usage, and related information.It is not a full statement of Interchange and Control Structure rules. The full X12Interchange and Control Structures and other rules (X12.5, X12.6, X12.59, X12dictionaries, other X12 standards and official documents) apply unless specificallymodified in the detailed instructions of this implementation guide (seeSection B.1.1.3.1.2 - Decimal for an example of such a modification).

B.1.1.1 Interchange Control StructureThe transmission of data proceeds according to very strict format rules to ensure theintegrity and maintain the efficiency of the interchange. Each business grouping of datais called a transaction set. For instance, a group of benefit enrollments sent from asponsor to a payer is considered a transaction set.

Each transaction set contains groups of logically related data in units called segments.For instance, the N4 segment used in the transaction set conveys the city, state, ZIPCode, and other geographic information. A transaction set contains multiple segments,so the addresses of the different parties, for example, can be conveyed from onecomputer to the other. An analogy would be that the transaction set is like a freight train;the segments are like the train's cars; and each segment can contain several dataelements the same as a train car can hold multiple crates.

The sequence of the elements within one segment is specified by the ASC X12 standardas well as the sequence of segments in the transaction set. In a more conventionalcomputing environment, the segments would be equivalent to records, and the elementsequivalent to fields.

Similar transaction sets, called "functional groups," can be sent together within atransmission. Each functional group is prefaced by a group start segment; and a functionalgroup is terminated by a group end segment. One or more functional groups are prefacedby an interchange header and followed by an interchange trailer.Figure B.1 - Transmission Control Schematic, illustrates this interchange control.

B.1MAY 2006



Figure B.1 - Transmission Control Schematic

The interchange header and trailer segments envelop one or more functional groups orinterchange-related control segments and perform the following functions:

1. Define the data element separators and the data segment terminator.2. Identify the sender and receiver.3. Provide control information for the interchange.4. Allow for authorization and security information.

B.1.1.2 Application Control Structure Definitions and Concepts

B.1.1.2.1 Basic StructureA data element corresponds to a data field in data processing terminology. A datasegment corresponds to a record in data processing terminology. The data segment

MAY 2006B.2



begins with a segment ID and contains related data elements. A control segment hasthe same structure as a data segment; the distinction is in the use. The data segmentis used primarily to convey user information, but the control segment is used primarilyto convey control information and to group data segments.

B.1.1.2.2 Basic Character SetThe section that follows is designed to have representation in the common charactercode schemes of EBCDIC, ASCII, and CCITT International Alphabet 5. The ASC X12standards are graphic-character-oriented; therefore, common character encodingschemes other than those specified herein may be used as long as a common mappingis available. Because the graphic characters have an implied mapping across charactercode schemes, those bit patterns are not provided here.

The basic character set of this standard, shown in Table B.1 - Basic Character Set,includes those selected from the uppercase letters, digits, space, and special charactersas specified below.

Table B.1 - Basic Character Set

* + ) ( & ! 0...9 A...Z

(space) = ? ; : / . - ,

B.1.1.2.3 Extended Character SetAn extended character set may be used by negotiation between the two parties andincludes the lowercase letters and other special characters as specified inTable B.2 - Extended Character Set.

Table B.2 - Extended Character Set

{ _ ] [ @ ~ % a...z

$ # > < | \ }

Note that the extended characters include several character codes that have multiplegraphical representations for a specific bit pattern. The complete list appears in otherstandards such as CCITT S.5. Use of the USA graphics for these codes presents noproblem unless data is exchanged with an international partner. Other problems, suchas the translation of item descriptions from English to French, arise when exchangingdata with an international partner, but minimizing the use of codes with multiple graphicseliminates one of the more obvious problems.

B.3MAY 2006



tdrinkard

Text Box

Please include the corrected versions of the Basic Character Set and the Extended Character Set.

For implementations compliant with this guide, either the entire extended character setmust be acceptable, or the entire extended character set must not be used. In theabsence of a specific trading partner agreement to the contrary, trading partners willassume that the extended character set is acceptable. Use of the extended characterset allows the use of the "@" character in email addresses within the PER segment.Users should note that characters in the extended character set, as well as the basiccharacter set, may be used as delimiters only when they do not occur in the data asstated in Section B.1.1.2.4.1 - Base Control Set.

B.1.1.2.4 Control CharactersTwo control character groups are specified; they have restricted usage. The commonnotation for these groups is also provided, together with the character coding in threecommon alphabets. In Table B.3 - Base Control Set, the column IA5 represents CCITTV.3 International Alphabet 5.

B.1.1.2.4.1 Base Control SetThe base control set includes those characters that will not have a disruptive effect onmost communication protocols. These are represented by:

Table B.3 - Base Control Set

IA5ASCIIEBCDICNAMENOTATION

07072FbellBEL

090905horizontal tabHT

0A0A25line feedLF

0B0B0Bvertical tabVT

0C0C0Cform feedFF

0D0D0Dcarriage returnCR

1C1C1Cfile separatorFS

1D1D1Dgroup separatorGS

1E1E1Erecord separatorRS

1F1F1Funit separatorUS

15new lineNL

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The Group Separator (GS) may be an exception in this set because it is used in the3780 communications protocol to indicate blank space compression.

B.1.1.2.4.2 Extended Control SetThe extended control set includes those that may have an effect on a transmissionsystem. These are shown in Table B.4 - Extended Control Set.

Table B.4 - Extended Control Set

IA5ASCIIEBCDICNAMENOTATION

010101start of headerSOH

020202start of textSTX

030303end of textETX

040437end of transmissionEOT

05052DenquiryENQ

06062EacknowledgeACK

111111device control 1DC1



14143Cdevice control 4DC4

15153Dnegative acknowledgeNAK

161632synchronous idleSYN

171726end of blockETB

B.1.1.2.5 DelimitersA delimiter is a character used to separate two data elements or component elementsor to terminate a segment. The delimiters are an integral part of the data.

Delimiters are specified in the interchange header segment, ISA. The ISA segment canbe considered in implementations compliant with this guide (see Appendix C, ISASegment Note 1) to be a 105 byte fixed length record, followed by a segment terminator.The data element separator is byte number 4; the repetition separator is byte number

B.5MAY 2006



83; the component element separator is byte number 105; and the segment terminatoris the byte that immediately follows the component element separator.

Once specified in the interchange header, the delimiters are not to be used in a dataelement value elsewhere in the interchange. For consistency, this implementation guideuses the delimiters shown in Table B.5 - Delimiters, in all examples of EDI transmissions.

Table B.5 - Delimiters

DELIMITERNAMECHARACTER

Data Element SeparatorAsterisk*

Repetition SeparatorCarat^

Component Element SeparatorColon:

Segment TerminatorTilde~

The delimiters above are for illustration purposes only and are not specificrecommendations or requirements. Users of this implementation guide should be awarethat an application system may use some valid delimiter characters within the applicationdata. Occurrences of delimiter characters in transmitted data within a data element willresult in errors in translation.The existence of asterisks (*) within transmitted applicationdata is a known issue that can affect translation software.

B.1.1.3 Business Transaction Structure Definitions and ConceptsThe ASC X12 standards define commonly used business transactions (such as a healthcare claim) in a formal structure called "transaction sets." A transaction set is composedof a transaction set header control segment, one or more data segments, and atransaction set trailer control segment. Each segment is composed of the following:

• A unique segment ID• One or more logically related data elements each preceded by a data element separator• A segment terminator

B.1.1.3.1 Data ElementThe data element is the smallest named unit of information in the ASC X12 standard.Data elements are identified as either simple or component. A data element that occursas an ordinally positioned member of a composite data structure is identified as acomponent data element. A data element that occurs in a segment outside the definedboundaries of a composite data structure is identified as a simple data element. The

MAY 2006B.6



distinction between simple and component data elements is strictly a matter of contextbecause a data element can be used in either capacity.

Data elements are assigned a unique reference number. Each data element has a name,description, type, minimum length, and maximum length. For ID type data elements, thisguide provides the applicable ASC X12 code values and their descriptions or referenceswhere the valid code list can be obtained.

A simple data element within a segment may have an attribute indicating that it mayoccur once or a specific number of times more than once. The number of permittedrepeats are defined as an attribute in the individual segment where the repeated dataelement occurs.

Each data element is assigned a minimum and maximum length. The length of the dataelement value is the number of character positions used except as noted for numeric,decimal, and binary elements.

The data element types shown in Table B.6 - Data Element Types, appear in thisimplementation guide.

Table B.6 - Data Element Types

TYPESYMBOL

NumericNn

DecimalR

IdentifierID

StringAN

DateDT

TimeTM

BinaryB

The data element minimum and maximum lengths may be restricted in this implementationguide for a compliant implementation. Such restrictions may occur by virtue of the allowedqualifier for the data element or by specific instructions regarding length or format asstated in this implementation guide.

B.7MAY 2006



B.1.1.3.1.1 NumericA numeric data element is represented by one or more digits with an optional leadingsign representing a value in the normal base of 10.The value of a numeric data elementincludes an implied decimal point. It is used when the position of the decimal point withinthe data is permanently fixed and is not to be transmitted with the data.

This set of guides denotes the number of implied decimal positions. The representationfor this data element type is "Nn" where N indicates that it is numeric and n indicatesthe number of decimal positions to the right of the implied decimal point.

If n is 0, it need not appear in the specification; N is equivalent to N0. For negative values,the leading minus sign (-) is used. Absence of a sign indicates a positive value.The plussign (+) must not be transmitted.

EXAMPLEA transmitted value of 1234, when specified as numeric type N2, represents a value of12.34.

Leading zeros must be suppressed unless necessary to satisfy a minimum lengthrequirement. The length of a numeric type data element does not include the optionalsign.

B.1.1.3.1.2 DecimalA decimal data element may contain an explicit decimal point and is used for numericvalues that have a varying number of decimal positions. This data element type isrepresented as "R."

The decimal point always appears in the character stream if the decimal point is at anyplace other than the right end. If the value is an integer (decimal point at the right end)the decimal point must be omitted. For negative values, the leading minus sign (-) isused. Absence of a sign indicates a positive value. The plus sign (+) must not betransmitted.

Leading zeros must be suppressed unless necessary to satisfy a minimum lengthrequirement. Trailing zeros following the decimal point must be suppressed unlessnecessary to indicate precision. The use of triad separators (for example, the commasin 1,000,000) is expressly prohibited. The length of a decimal type data element doesnot include the optional leading sign or decimal point.

EXAMPLEA transmitted value of 12.34 represents a decimal value of 12.34.

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While the ASC X12 standard supports usage of exponential notation, this guide prohibitsthat usage.

For implementation of this guide under the rules promulgated under the Health InsurancePortability and Accountability Act (HIPAA), decimal data elements in Data Element 782(Monetary Amount) will be limited to a maximum length of 10 characters including reportedor implied places for cents (implied value of 00 after the decimal point). Note the statementin the preceding paragraph that the decimal point and leading sign, if sent, are not partof the character count.

EXAMPLEFor implementations mandated under HIPAA rules:

• The following transmitted value represents the largest positive dollar amount that canbe sent: 99999999.99

• The following transmitted value is the longest string of characters that can be sentrepresenting whole dollars: 99999999

• The following transmitted value is the longest string of characters that can be sentrepresenting negative dollars and cents: -99999999.99

• The following transmitted value is the longest string of characters that can be sentrepresenting negative whole dollars: -99999999

B.1.1.3.1.3 IdentifierAn identifier data element always contains a value from a predefined list of codes thatis maintained by the ASC X12 Committee or some other body recognized by theCommittee. Trailing spaces must be suppressed unless they are necessary to satisfy aminimum length. An identifier is always left justified. The representation for this dataelement type is "ID."

B.1.1.3.1.4 StringA string data element is a sequence of any characters from the basic or extendedcharacter sets. The string data element must contain at least one non-space character.The significant characters shall be left justified. Leading spaces, when they occur, arepresumed to be significant characters. Trailing spaces must be suppressed unless theyare necessary to satisfy a minimum length. The representation for this data elementtype is "AN."

B.1.1.3.1.5 DateA date data element is used to express the standard date in either YYMMDD orCCYYMMDD format in which CC is the first two digits of the calendar year, YY is thelast two digits of the calendar year, MM is the month (01 to 12), and DD is the day in the

B.9MAY 2006



month (01 to 31). The representation for this data element type is "DT." Users of thisguide should note that all dates within transactions are 8-character dates (millenniumcompliant) in the format CCYYMMDD. The only date data element that is in formatYYMMDD is the Interchange Date data element in the ISA segment and the TA1 segmentwhere the century is easily determined because of the nature of an interchange header.

B.1.1.3.1.6 TimeA time data element is used to express the ISO standard time HHMMSSd..d format inwhich HH is the hour for a 24 hour clock (00 to 23), MM is the minute (00 to 59), SS isthe second (00 to 59) and d..d is decimal seconds. The representation for this dataelement type is "TM." The length of the data element determines the format of thetransmitted time.

EXAMPLETransmitted data elements of four characters denote HHMM.Transmitted data elementsof six characters denote HHMMSS.

B.1.1.3.1.7 BinaryThe binary data element is any sequence of octets ranging in value from binary 00000000to binary 11111111. This data element type has no defined maximum length. Actuallength is specified by the immediately preceding data element. Within the body of atransaction set (from ST to SE) implemented according to this technical report, the binarydata element type is only used in the segments Binary Data Segment BIN, and BinaryData Structure BDS. Within those segments, Data Element 785 Binary Data is a stringof octets which can assume any binary pattern from hexadecimal 00 to FF, and can beused to send text as well as coded data, including data from another application in itsnative format. The binary data type is also used in some control and security structures.

Not all transaction sets use the Binary Data Segment BIN or Binary Data Structure BDS.

B.1.1.3.2 Repeating Data ElementsSimple or composite data elements within a segment can be designated as repeatingdata elements. Repeating data elements are adjacent data elements that occur up to anumber of times specified in the standard as number of repeats. The implementationguide may also specify the number of repeats of a repeating data element in a specificlocation in the transaction that are permitted in a compliant implementation. Adjacentoccurrences of the same repeating simple data element or composite data structure ina segment shall be separated by a repetition separator.

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B.1.1.3.3 Composite Data StructureThe composite data structure is an intermediate unit of information in a segment.Composite data structures are composed of one or more logically related simple dataelements, each, except the last, followed by a sub-element separator. The final dataelement is followed by the next data element separator or the segment terminator. Eachsimple data element within a composite is called a component.

Each composite data structure has a unique four-character identifier, a name, and apurpose. The identifier serves as a label for the composite. A composite data structurecan be further defined through the use of syntax notes, semantic notes, and comments.Each component within the composite is further characterized by a reference designatorand a condition designator. The reference designators and the condition designatorsare described in Section B.1.1.3.8 - Reference Designator andSection B.1.1.3.9 - Condition Designator.

A composite data structure within a segment may have an attribute indicating that it mayoccur once or a specific number of times more than once. The number of permittedrepeats are defined as an attribute in the individual segment where the repeatedcomposite data structure occurs.

B.1.1.3.4 Data SegmentThe data segment is an intermediate unit of information in a transaction set. In the datastream, a data segment consists of a segment identifier, one or more composite datastructures or simple data elements each preceded by a data element separator andsucceeded by a segment terminator.

Each data segment has a unique two- or three-character identifier, a name, and apurpose.The identifier serves as a label for the data segment. A segment can be furtherdefined through the use of syntax notes, semantic notes, and comments. Each simpledata element or composite data structure within the segment is further characterized bya reference designator and a condition designator.

B.1.1.3.5 Syntax NotesSyntax notes describe relational conditions among two or more data segment units withinthe same segment, or among two or more component data elements within the samecomposite data structure. For a complete description of the relational conditions, SeeSection B.1.1.3.9 - Condition Designator.

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B.1.1.3.6 Semantic NotesSimple data elements or composite data structures may be referenced by a semanticnote within a particular segment. A semantic note provides important additionalinformation regarding the intended meaning of a designated data element, particularlya generic type, in the context of its use within a specific data segment. Semantic notesmay also define a relational condition among data elements in a segment based on thepresence of a specific value (or one of a set of values) in one of the data elements.

B.1.1.3.7 CommentsA segment comment provides additional information regarding the intended use of thesegment.

B.1.1.3.8 Reference DesignatorEach simple data element or composite data structure in a segment is provided astructured code that indicates the segment in which it is used and the sequential positionwithin the segment.The code is composed of the segment identifier followed by a two-digitnumber that defines the position of the simple data element or composite data structurein that segment.

For purposes of creating reference designators, the composite data structure is viewedas the hierarchical equal of the simple data element. Each component data element ina composite data structure is identified by a suffix appended to the reference designatorfor the composite data structure of which it is a member. This suffix is prefixed with ahyphen and defines the position of the component data element in the composite datastructure.

EXAMPLE

• The first simple element of the CLP segment would be identified as CLP01.• The first position in the SVC segment is occupied by a composite data structure that

contains seven component data elements, the reference designator for the secondcomponent data element would be SVC01-02.

B.1.1.3.9 Condition DesignatorThis section provides information about X12 standard conditions designators. It is providedso that users will have information about the general standard. Implementation guidesmay impose other conditions designators. See implementation guide section 2.1Presentation Examples for detailed information about the implementation guide IndustryUsage requirements for compliant implementation.

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Data element conditions are of three types: mandatory, optional, and relational. Theydefine the circumstances under which a data element may be required to be present ornot present in a particular segment.

B.13MAY 2006



Table B.7 - Condition Designator

DESCRIPTIONDESIGNATOR

The designation of mandatory is absolute in the sense that there isno dependency on other data elements. This designation may apply

M- Mandatory

to either simple data elements or composite data structures. If thedesignation applies to a composite data structure, then at least onevalue of a component data element in that composite data structureshall be included in the data segment.

The designation of optional means that there is no requirement fora simple data element or composite data structure to be present in

O- Optional

the segment. The presence of a value for a simple data element orthe presence of value for any of the component data elements of acomposite data structure is at the option of the sender.

Relational conditions may exist among two or more simple dataelements within the same data segment based on the presence or

X- Relational

absence of one of those data elements (presence means a dataelement must not be empty). Relational conditions are specified bya condition code (see table below) and the reference designators ofthe affected data elements. A data element may be subject to morethan one relational condition.

The definitions for each of the condition codes used within syntaxnotes are detailed below:

DEFINITIONCONDITION CODE

If any element specified in the relationalcondition is present, then all of the elementsspecified must be present.

P- Paired or Multiple

At least one of the elements specified in thecondition must be present.

R- Required

Not more than one of the elements specifiedin the condition may be present.

E- Exclusion

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If the first element specified in the condition ispresent, then all other elements must bepresent. However, any or all of the elementsnot specified as the first element in thecondition may appear without requiring thatthe first element be present. The order of theelements in the condition does not have to bethe same as the order of the data elements inthe data segment.

C- Conditional

If the first element specified in the condition ispresent, then at least one of the remainingelements must be present. However, any orall of the elements not specified as the firstelement in the condition may appear withoutrequiring that the first element be present.Theorder of the elements in the condition does nothave to be the same as the order of the dataelements in the data segment.

L- List Conditional

B.1.1.3.10 Absence of DataAny simple data element that is indicated as mandatory must not be empty if the segmentis used. At least one component data element of a composite data structure that isindicated as mandatory must not be empty if the segment is used. Optional simple dataelements and/or composite data structures and their preceding data element separatorsthat are not needed must be omitted if they occur at the end of a segment. If they do notoccur at the end of the segment, the simple data element values and/or composite datastructure values may be omitted. Their absence is indicated by the occurrence of theirpreceding data element separators, in order to maintain the element's or structure'sposition as defined in the data segment.

Likewise, when additional information is not necessary within a composite, the compositemay be terminated by providing the appropriate data element separator or segmentterminator.

If a segment has no data in any data element within the segment (an "empty" segment),that segment must not be sent.

B.15MAY 2006



B.1.1.3.11 Control SegmentsA control segment has the same structure as a data segment, but it is used for transferringcontrol information rather than application information.

B.1.1.3.11.1 Loop Control SegmentsLoop control segments are used only to delineate bounded loops. Delineation of theloop shall consist of the loop header (LS segment) and the loop trailer (LE segment).The loop header defines the start of a structure that must contain one or more iterationsof a loop of data segments and provides the loop identifier for this loop. The loop trailerdefines the end of the structure.The LS segment appears only before the first occurrenceof the loop, and the LE segment appears only after the last occurrence of the loop.Unbounded looping structures do not use loop control segments.

B.1.1.3.11.2 Transaction Set Control SegmentsThe transaction set is delineated by the transaction set header (ST segment) and thetransaction set trailer (SE segment). The transaction set header identifies the start andidentifier of the transaction set. The transaction set trailer identifies the end of thetransaction set and provides a count of the data segments, which includes the ST andSE segments.

B.1.1.3.11.3 Functional Group Control SegmentsThe functional group is delineated by the functional group header (GS segment) andthe functional group trailer (GE segment).The functional group header starts and identifiesone or more related transaction sets and provides a control number and applicationidentification information. The functional group trailer defines the end of the functionalgroup of related transaction sets and provides a count of contained transaction sets.

B.1.1.3.11.4 Relations among Control SegmentsThe control segment of this standard must have a nested relationship as is shown andannotated in this subsection. The letters preceding the control segment name are thesegment identifier for that control segment.The indentation of segment identifiers shownbelow indicates the subordination among control segments.

GS Functional Group Header, starts a group of related transaction sets.

ST Transaction Set Header, starts a transaction set.

LS Loop Header, starts a bounded loop of data segments but is not part of theloop.

LS Loop Header, starts an inner, nested, bounded loop.

LE Loop Trailer, ends an inner, nested bounded loop.

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LE Loop Trailer, ends a bounded loop of data segments but is not part of theloop.

SE Transaction Set Trailer, ends a transaction set.

GE Functional Group Trailer, ends a group of related transaction sets.

More than one ST/SE pair, each representing a transaction set, may be used within onefunctional group. Also more than one LS/LE pair, each representing a bounded loop,may be used within one transaction set.

B.1.1.3.12 Transaction SetThe transaction set is the smallest meaningful set of information exchanged betweentrading partners. The transaction set consists of a transaction set header segment, oneor more data segments in a specified order, and a transaction set trailer segment. SeeFigure B.1 - Transmission Control Schematic.

B.1.1.3.12.1 Transaction Set Header and TrailerA transaction set identifier uniquely identifies a transaction set. This identifier is the firstdata element of the Transaction Set Header Segment (ST). A user assigned transactionset control number in the header must match the control number in the Trailer Segment(SE) for any given transaction set. The value for the number of included segments inthe SE segment is the total number of segments in the transaction set, including the STand SE segments.

B.1.1.3.12.2 Data Segment GroupsThe data segments in a transaction set may be repeated as individual data segmentsor as unbounded or bounded loops.

B.1.1.3.12.3 Repeated Occurrences of Single Data SegmentsWhen a single data segment is allowed to be repeated, it may have a specified maximumnumber of occurrences defined at each specified position within a given transaction setstandard. Alternatively, a segment may be allowed to repeat an unlimited number oftimes. The notation for an unlimited number of repetitions is ">1."

B.1.1.3.12.4 Loops of Data SegmentsLoops are groups of semantically related segments. Data segment loops may beunbounded or bounded.

Unbounded LoopsTo establish the iteration of a loop, the first data segment in the loop must appear onceand only once in each iteration. Loops may have a specified maximum number of

B.17MAY 2006



repetitions. Alternatively, the loop may be specified as having an unlimited number ofiterations. The notation for an unlimited number of repetitions is ">1."

A specified sequence of segments is in the loop. Loops themselves are optional ormandatory. The requirement designator of the beginning segment of a loop indicateswhether at least one occurrence of the loop is required. Each appearance of the beginningsegment defines an occurrence of the loop.

The requirement designator of any segment within the loop after the beginning segmentapplies to that segment for each occurrence of the loop. If there is a mandatoryrequirement designator for any data segment within the loop after the beginning segment,that data segment is mandatory for each occurrence of the loop. If the loop is optional,the mandatory segment only occurs if the loop occurs.

Bounded LoopsThe characteristics of unbounded loops described previously also apply to boundedloops. In addition, bounded loops require a Loop Start Segment (LS) to appear beforethe first occurrence and a Loop End Segment (LE) to appear after the last consecutiveoccurrence of the loop. If the loop does not occur, the LS and LE segments aresuppressed.

B.1.1.3.12.5 Data Segments in a Transaction SetWhen data segments are combined to form a transaction set, three characteristics areapplied to each data segment: a requirement designator, a position in the transactionset, and a maximum occurrence.

B.1.1.3.12.6 Data Segment Requirement DesignatorsA data segment, or loop, has one of the following requirement designators for healthcare and insurance transaction sets, indicating its appearance in the data stream of atransmission. These requirement designators are represented by a single charactercode.

Table B.8 - Data Segment Requirement Designators


This data segment must be included in the transaction set. (Notethat a data segment may be mandatory in a loop of data segments,but the loop itself is optional if the beginning segment of the loop isdesignated as optional.)

M- Mandatory

The presence of this data segment is the option of the sending party.O- Optional

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B.1.1.3.12.7 Data Segment PositionThe ordinal positions of the segments in a transaction set are explicitly specified for thattransaction. Subject to the flexibility provided by the optional requirement designatorsof the segments, this positioning must be maintained.

B.1.1.3.12.8 Data Segment OccurrenceA data segment may have a maximum occurrence of one, a finite number greater thanone, or an unlimited number indicated by ">1."

B.1.1.3.13 Functional GroupA functional group is a group of similar transaction sets that is bounded by a functionalgroup header segment and a functional group trailer segment. The functional identifierdefines the group of transactions that may be included within the functional group. Thevalue for the functional group control number in the header and trailer control segmentsmust be identical for any given group. The value for the number of included transactionsets is the total number of transaction sets in the group. See Figure B.1 - TransmissionControl Schematic.

B.1.1.4 Envelopes and Control Structures

B.1.1.4.1 Interchange Control StructuresTypically, the term "interchange" connotes the ISA/IEA envelope that is transmittedbetween trading/business partners. Interchange control is achieved through several"control" components. The interchange control number is contained in data elementISA13 of the ISA segment.The identical control number must also occur in data element02 of the IEA segment. Most commercial translation software products will verify thatthese two elements are identical. In most translation software products, if these elementsare different the interchange will be "suspended" in error.

There are many other features of the ISA segment that are used for control measures.For instance, the ISA segment contains data elements such as authorization information,security information, sender identification, and receiver identification that can be usedfor control purposes.These data elements are agreed upon by the trading partners priorto transmission.The interchange date and time data elements as well as the interchangecontrol number within the ISA segment are used for debugging purposes when there isa problem with the transmission or the interchange.

Data Element ISA12, Interchange Control Version Number, indicates the version of theISA/IEA envelope. GS08 indicates the version of the transaction sets contained withinthe ISA/IEA envelope. The versions are not required to be the same. An Interchange

B.19MAY 2006



Acknowledgment can be requested through data element ISA14. The interchangeacknowlegement is the TA1 segment. Data element ISA15, Test Indicator, is usedbetween trading partners to indicate that the transmission is in a "test" or "production"mode. Data element ISA16, Subelement Separator, is used by the translator forinterpretation of composite data elements.

The ending component of the interchange or ISA/IEA envelope is the IEA segment. Dataelement IEA01 indicates the number of functional groups that are included within theinterchange. In most commercial translation software products, an aggregate count offunctional groups is kept while interpreting the interchange. This count is then verifiedwith data element IEA01. If there is a discrepancy, in most commercial products, theinterchange is suspended. The other data element in the IEA segment is IEA02 whichis referenced above.

See Appendix C, EDI Control Directory, for a complete detailing of the inter-changecontrol header and trailer. The authors recommend that when two transactions withdifferent X12 versions numbers are sent in one interchange control structure (multiplefunctional groups within one ISA/IEA envelope), the Interchange Control version usedshould be that of the most recent transaction version included in the envelope. For thetransmission of HIPAA transactions with mixed versions, this would be a compliantenveloping structure.

B.1.1.4.2 Functional GroupsControl structures within the functional group envelope include the functional identifiercode in GS01. The Functional Identifier Code is used by the commercial translationsoftware during interpretation of the interchange to determine the different transactionsets that may be included within the functional group. If an inappropriate transaction setis contained within the functional group, most commercial translation software will suspendthe functional group within the interchange.The Application Sender's Code in GS02 canbe used to identify the sending unit of the transmission.The Application Receiver's Codein GS03 can be used to identify the receiving unit of the transmission. The functionalgroup contains a creation date (GS04) and creation time (GS05) for the functional group.The Group Control Number is contained in GS06. These data elements (GS04, GS05,and GS06) can be used for debugging purposes. GS08,Version/Release/Industry IdentifierCode is the version/release/sub-release of the transaction sets being transmitted in thisfunctional group.

The Functional Group Control Number in GS06 must be identical to data element 02 ofthe GE segment. Data element GE01 indicates the number of transaction sets withinthe functional group. In most commercial translation software products, an aggregate

MAY 2006B.20



count of the transaction sets is kept while interpreting the functional group. This countis then verified with data element GE01.

See Appendix C, EDI Control Directory, for a complete detailing of the functional groupheader and trailer.

B.1.1.4.3 HL StructuresThe HL segment is used in several X12 transaction sets to identify levels of detailinformation using a hierarchical structure, such as relating dependents to a subscriber.Hierarchical levels may differ from guide to guide.

For example, each provider can bill for one or more subscribers, each subscriber canhave one or more dependents and the subscriber and the dependents can make oneor more claims.

Each guide states what levels are available, the level's usage, number of repeats, andwhether that level has subordinate levels within a transaction set.

For implementations compliant with this guide, the repeats of the loops identified by theHL structure shall appear in the hierarchical order specified in BHT01, when thoseparticular hierarchical levels exist. That is, an HL parent loop must be followed by thesubordinate child loops, if any, prior to commencing a new HL parent loop at the samehierarchical level.

The following diagram, from transaction set 837, illustrates a typical hierarchy.

The two examples below illustrate this requirement:

Example 1 based on Implementation Guide 811X201:INSURER

First STATE in transaction (child of INSURER)First POLICY in transaction (child of first STATE)

First VEHICLE in transaction (child of first POLICY)Second POLICY in transaction (child of first STATE)

Second VEHICLE in transaction (child of second POLICY)Third VEHICLE in transaction (child of second POLICY)

B.21MAY 2006



Second STATE in transaction (child of INSURER)Third POLICY in transaction (child of second STATE)

Fourth VEHICLE in transaction (child of third POLICY)

Example 2 based on Implementation Guide 837X141First PROVIDER in transaction

First SUBSCRIBER in transaction (child of first PROVIDER)Second PROVIDER in transaction

Second SUBSCRIBER in transaction (child of second PROVIDER)First DEPENDENT in transaction (child of second SUBSCRIBER)Second DEPENDENT in transaction (child of second SUBSCRIBER)

Third SUBSCRIBER in transaction (child of second PROVIDER)Third PROVIDER in transaction

Fourth SUBSCRIBER in transaction (child of third PROVIDER)Fifth SUBSCRIBER in transaction (child of third PROVIDER)

Third DEPENDENT in transaction (child of fifth SUBSCRIBER)

B.1.1.5 Acknowledgments

B.1.1.5.1 Interchange Acknowledgment,TA1The TA1 segment provides the capability for the interchange receiver to notify the senderthat a valid envelope was received or that problems were encountered with theinterchange control structure. The TA1 verifies the envelopes only. Transactionset-specific verification is accomplished through use of the Functional AcknowledgmentTransaction Set, 997. See Section B.1.1.5.2 - Functional Acknowledgment, 997, formore details. The TA1 is unique in that it is a single segment transmitted without theGS/GE envelope structure. A TA1 can be included in an interchange with other functionalgroups and transactions.

Encompassed in the TA1 are the interchange control number, interchange date andtime, interchange acknowledgment code, and the interchange note code.The interchangecontrol number, interchange date and time are identical to those that were present inthe transmitted interchange from the trading partner. This provides the capability toassociate the TA1 with the transmitted interchange.TA104, Interchange AcknowledgmentCode, indicates the status of the interchange control structure. This data elementstipulates whether the transmitted interchange was accepted with no errors, acceptedwith errors, or rejected because of errors.TA105, Interchange Note Code, is a numericalcode that indicates the error found while processing the interchange control structure.Values for this data element indicate whether the error occurred at the interchange orfunctional group envelope.

MAY 2006B.22



B.1.1.5.2 Functional Acknowledgment, 997The Functional Acknowledgment Transaction Set, 997, has been designed to allowtrading partners to establish a comprehensive control function as a part of their businessexchange process. This acknowledgment process facilitates control of EDI. There is aone-to-one correspondence between a 997 and a functional group. Segments within the997 can identify the acceptance or rejection of the functional group, transaction sets orsegments. Data elements in error can also be identified. There are many EDIimplementations that have incorporated the acknowledgment process in all of theirelectronic communications. The 997 is used as a functional acknowledgment to apreviously transmitted functional group.

The 997 is a transaction set and thus is encapsulated within the interchange controlstructure (envelopes) for transmission.

B.2 Object DescriptorsObject Descriptors (OD) provide a method to uniquely identify specific locations withinan implementation guide. There is an OD assigned at every level of the X12Nimplementation:

1. Transaction Set2. Loop3. Segment4. Composite Data Element5. Component Data Element6. Simple Data Element

ODs at the first four levels are coded using X12 identifiers separated by underbars:

ExampleEntity

837Q11. Transaction Set Identifier plus a unique 2 charactervalue

837Q1_2330C2. Above plus under bar plus Loop Identifier as assignedwithin an implementation guide

837Q1_2330C_NM13. Above plus under bar plus Segment Identifier

837Q1_2400_SV101_C0034. Above plus Reference Designator plus under bar plusComposite Identifier

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The fifth and sixth levels add a name derived from the "Industry Term" defined in theX12N Data Dictionary. The name is derived by removing the spaces.

ExampleEntity

837Q1_2400_SV101_C00302_ProcedureCode5. Number4 abovepluscompositesequenceplus underbar plusname

837Q1_2330C_NM109__OtherPayerPatientPrimaryIdentifier6. Number3 aboveplusReferenceDesignatorplus twounder barsplus name

Said in another way, ODs contain a coded component specifying a location in animplementation guide, a separator, and a name portion. For example:

Since ODs are unique across all X12N implementation guides, they can be used for avariety of purposes. For example, as a cross reference to older data transmissionsystems, like the National Standard Format for health care claims, or to form XML tagsfor newer data transmission systems.

MAY 2006B.24



C EDI Control Directory

C.1 Control Segments• ISA

Interchange Control Header Segment

• GSFunctional Group Header Segment

• GEFunctional Group Trailer Segment

• IEAInterchange Control Trailer Segment


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C.2 MAY 2006

005010X000 • 002

MAY 4, 2004ISAINTERCHANGE CONTROL HEADER 005010X000 • 002 • ISAINTERCHANGE CONTROL HEADER

SEGMENT DETAIL

ISA - INTERCHANGE CONTROL HEADERX12 Segment Name: Interchange Control Header

X12 Purpose: To start and identify an interchange of zero or more functional groups andinterchange-related control segments

Segment Repeat: 1

Usage: REQUIRED

2 TR3 Notes: 1. All positions within each of the data elements must be filled.

3 2. For compliant implementations under this implementation guide,ISA13, the interchange Control Number, must be a positive unsignednumber. Therefore, the ISA segment can be considered a fixed recordlength segment.

4 3. The first element separator defines the element separator to be usedthrough the entire interchange.

5 4. The ISA segment terminator defines the segment terminator usedthroughout the entire interchange.

6 5. Spaces in the example interchanges are represented by “.” for clarity.

1000001 TR3 Example: ISA✽ 00✽ ..........✽ 01✽ SECRET....✽ ZZ✽ SUBMITTERS.ID..✽ ZZ✽

RECEIVERS.ID...✽ 030101✽ 1253✽ ^✽ 00501✽ 000000905✽ 1✽ T✽ :~

DIAGRAM

ISA01 I01 ISA02 I02 ISA03 I03 ISA04 I04 ISA05 I05 ISA06 I06

ISA ✽ Author InfoQualifier ✽ Author

Information ✽ SecurityInfo Qual ✽ Security

Information ✽ InterchangeID Qual ✽ Interchange

Sender IDM 1 ID 2/2 M 1 AN 10/10 M 1 ID 2/2 M 1 AN 10/10 M 1 ID 2/2 M 1 AN 15/15

ISA07 I05 ISA08 I07 ISA09 I08 ISA10 I09 ISA11 I65 ISA12 I11

✽ InterchangeID Qual ✽ Interchange

Receiver ID ✽ InterchangeDate ✽ Interchange

Time ✽ RepetitionSeparator ✽ Inter Ctrl

Version NumM 1 ID 2/2 M 1 AN 15/15 M 1 DT 6/6 M 1 TM 4/4 M 1 1/1 M 1 ID 5/5

ISA13 I12 ISA14 I13 ISA15 I14 ISA16 I15

✽ Inter CtrlNumber ✽ Ack

Requested ✽ UsageIndicator ✽ Component

Elem Sepera ~

M 1 N0 9/9 M 1 ID 1/1 M 1 ID 1/1 M 1 1/1

ASC X12N • INSURANCE SUBCOMMITTEETECHNICAL REPORT • TYPE 3 CONTROL SEGMENTS

MAY 2006 C.3

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED ISA01 I01 Authorization Information Qualifier M 1 ID 2/2Code identifying the type of information in the Authorization Information

CODE DEFINITION

00 No Authorization Information Present (NoMeaningful Information in I02)

03 Additional Data IdentificationREQUIRED ISA02 I02 Authorization Information M 1 AN 10/10

Information used for additional identification or authorization of the interchangesender or the data in the interchange; the type of information is set by theAuthorization Information Qualifier (I01)

REQUIRED ISA03 I03 Security Information Qualifier M 1 ID 2/2Code identifying the type of information in the Security Information

CODE DEFINITION

00 No Security Information Present (No MeaningfulInformation in I04)

01 PasswordREQUIRED ISA04 I04 Security Information M 1 AN 10/10

This is used for identifying the security information about the interchange senderor the data in the interchange; the type of information is set by the SecurityInformation Qualifier (I03)

REQUIRED ISA05 I05 Interchange ID Qualifier M 1 ID 2/2Code indicating the system/method of code structure used to designate thesender or receiver ID element being qualified

1000002 This ID qualifies the Sender in ISA06.

CODE DEFINITION

01 Duns (Dun & Bradstreet)

14 Duns Plus Suffix

20 Health Industry Number (HIN)

CODE SOURCE 121: Health Industry Number27 Carrier Identification Number as assigned by Health

Care Financing Administration (HCFA)

28 Fiscal Intermediary Identification Number asassigned by Health Care Financing Administration(HCFA)

29 Medicare Provider and Supplier IdentificationNumber as assigned by Health Care FinancingAdministration (HCFA)

30 U.S. Federal Tax Identification Number

33 National Association of Insurance CommissionersCompany Code (NAIC)

ZZ Mutually DefinedREQUIRED ISA06 I06 Interchange Sender ID M 1 AN 15/15

Identification code published by the sender for other parties to use as the receiverID to route data to them; the sender always codes this value in the sender IDelement

ASC X12N • INSURANCE SUBCOMMITTEECONTROL SEGMENTS TECHNICAL REPORT • TYPE 3

C.4 MAY 2006

REQUIRED ISA07 I05 Interchange ID Qualifier M 1 ID 2/2Code indicating the system/method of code structure used to designate thesender or receiver ID element being qualified

1000003 This ID qualifies the Receiver in ISA08.

CODE DEFINITION

01 Duns (Dun & Bradstreet)

14 Duns Plus Suffix

20 Health Industry Number (HIN)

CODE SOURCE 121: Health Industry Number27 Carrier Identification Number as assigned by Health

Care Financing Administration (HCFA)

28 Fiscal Intermediary Identification Number asassigned by Health Care Financing Administration(HCFA)

29 Medicare Provider and Supplier IdentificationNumber as assigned by Health Care FinancingAdministration (HCFA)

30 U.S. Federal Tax Identification Number

33 National Association of Insurance CommissionersCompany Code (NAIC)

ZZ Mutually DefinedREQUIRED ISA08 I07 Interchange Receiver ID M 1 AN 15/15

Identification code published by the receiver of the data; When sending, it is usedby the sender as their sending ID, thus other parties sending to them will use thisas a receiving ID to route data to them

REQUIRED ISA09 I08 Interchange Date M 1 DT 6/6Date of the interchange

1000006 The date format is YYMMDD.

REQUIRED ISA10 I09 Interchange Time M 1 TM 4/4Time of the interchange

1000007 The time format is HHMM.

REQUIRED ISA11 I65 Repetition Separator M 1 1/1Type is not applicable; the repetition separator is a delimiter and not a dataelement; this field provides the delimiter used to separate repeated occurrencesof a simple data element or a composite data structure; this value must bedifferent than the data element separator, component element separator, and thesegment terminator

REQUIRED ISA12 I11 Interchange Control Version Number M 1 ID 5/5Code specifying the version number of the interchange control segments

CODE DEFINITION

00501 Standards Approved for Publication by ASC X12Procedures Review Board through October 2003

REQUIRED ISA13 I12 Interchange Control Number M 1 N0 9/9A control number assigned by the interchange sender

1000004 The Interchange Control Number, ISA13, must be identical to theassociated Interchange Trailer IEA02.

7 Must be a positive unsigned number and must be identical to thevalue in IEA02.


MAY 2006 C.5

REQUIRED ISA14 I13 Acknowledgment Requested M 1 ID 1/1Code indicating sender’s request for an interchange acknowledgment

1000038 See Section B.1.1.5.1 for interchange acknowledgment information.

CODE DEFINITION

0 No Interchange Acknowledgment Requested

1 Interchange Acknowledgment Requested (TA1)REQUIRED ISA15 I14 Interchange Usage Indicator M 1 ID 1/1

Code indicating whether data enclosed by this interchange envelope is test,production or information

CODE DEFINITION

P Production Data

T Test DataREQUIRED ISA16 I15 Component Element Separator M 1 1/1

Type is not applicable; the component element separator is a delimiter and not adata element; this field provides the delimiter used to separate component dataelements within a composite data structure; this value must be different than thedata element separator and the segment terminator


C.6 MAY 2006

GSFUNCTIONAL GROUP HEADER 005010X000 • 002 • GSFUNCTIONAL GROUP HEADER

SEGMENT DETAIL

GS - FUNCTIONAL GROUP HEADERX12 Segment Name: Functional Group Header

X12 Purpose: To indicate the beginning of a functional group and to provide control information

X12 Comments: 1. A functional group of related transaction sets, within the scope of X12standards, consists of a collection of similar transaction sets enclosed by afunctional group header and a functional group trailer.

Segment Repeat: 1

Usage: REQUIRED

1000054 TR3 Example: GS✽ XX✽ SENDER CODE✽ RECEIVERCODE✽ 19991231✽ 0802✽ 1✽ X✽ 005010X223~

DIAGRAM

GS01 479 GS02 142 GS03 124 GS04 373 GS05 337 GS06 28

GS ✽ FunctionalID Code ✽ Application

Send’s Code ✽ ApplicationRec’s Code ✽ Date ✽ Time ✽ Group Ctrl

NumberM 1 ID 2/2 M 1 AN 2/15 M 1 AN 2/15 M 1 DT 8/8 M 1 TM 4/8 M 1 N0 1/9

GS07 455 GS08 480

✽ ResponsibleAgency Code ✽ Ver/Release

ID Code ~

M 1 ID 1/2 M 1 AN 1/12

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED GS01 479 Functional Identifier Code M 1 ID 2/2Code identifying a group of application related transaction sets

8 This is the 2-character Functional Identifier Code assigned to eachtransaction set by X12. The specific code for a transaction setdefined by this implementation guide is presented in section 1.2,Version Information.

REQUIRED GS02 142 Application Sender’s Code M 1 AN 2/15Code identifying party sending transmission; codes agreed to by trading partners

1000009 Use this code to identify the unit sending the information.

REQUIRED GS03 124 Application Receiver’s Code M 1 AN 2/15Code identifying party receiving transmission; codes agreed to by trading partners

1000010 Use this code to identify the unit receiving the information.

REQUIRED GS04 373 Date M 1 DT 8/8Date expressed as CCYYMMDD where CC represents the first two digits of thecalendar year

SEMANTIC: GS04 is the group date.

1000011 Use this date for the functional group creation date.


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005010X292

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REQUIRED GS05 337 Time M 1 TM 4/8Time expressed in 24-hour clock time as follows: HHMM, or HHMMSS, orHHMMSSD, or HHMMSSDD, where H = hours (00-23), M = minutes (00-59), S =integer seconds (00-59) and DD = decimal seconds; decimal seconds areexpressed as follows: D = tenths (0-9) and DD = hundredths (00-99)

SEMANTIC: GS05 is the group time.

1000012 Use this time for the creation time. The recommended format isHHMM.

REQUIRED GS06 28 Group Control Number M 1 N0 1/9Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GS06 in this header must beidentical to the same data element in the associated functional group trailer,GE02.

1000119 For implementations compliant with this guide, GS06 must beunique within a single transmission (that is, within a single ISA toIEA enveloping structure). The authors recommend that GS06 beunique within all transmissions over a period of time to bedetermined by the sender.

REQUIRED GS07 455 Responsible Agency Code M 1 ID 1/2Code identifying the issuer of the standard; this code is used in conjunction withData Element 480

CODE DEFINITION

X Accredited Standards Committee X12REQUIRED GS08 480 Version / Release / Industry Identifier Code M 1 AN 1/12

Code indicating the version, release, subrelease, and industry identifier of the EDIstandard being used, including the GS and GE segments; if code in DE455 in GSsegment is X, then in DE 480 positions 1-3 are the version number; positions 4-6are the release and subrelease, level of the version; and positions 7-12 are theindustry or trade association identifiers (optionally assigned by user); if code inDE455 in GS segment is T, then other formats are allowed

CODE SOURCE 881: Version / Release / Industry Identifier Code

9 This is the unique Version/Release/Industry Identifier Codeassigned to an implementation by X12N. The specific code for atransaction set defined by this implementation guide is presentedin section 1.2, Version Information.

CODE DEFINITION

005010X223 Standards Approved for Publication by ASC X12Procedures Review Board through October 2003


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005010X292

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GEFUNCTIONAL GROUP TRAILER 005010X000 • 002 • GEFUNCTIONAL GROUP TRAILER

SEGMENT DETAIL

GE - FUNCTIONAL GROUP TRAILERX12 Segment Name: Functional Group Trailer

X12 Purpose: To indicate the end of a functional group and to provide control information

X12 Comments: 1. The use of identical data interchange control numbers in the associatedfunctional group header and trailer is designed to maximize functionalgroup integrity. The control number is the same as that used in thecorresponding header.

Segment Repeat: 1

Usage: REQUIRED

1000013 TR3 Example: GE✽ 1✽ 1~

DIAGRAM

GE01 97 GE02 28

GE ✽ Number ofTS Included ✽ Group Ctrl

Number ~

M 1 N0 1/6 M 1 N0 1/9

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED GE01 97 Number of Transaction Sets Included M 1 N0 1/6Total number of transaction sets included in the functional group or interchange(transmission) group terminated by the trailer containing this data element

REQUIRED GE02 28 Group Control Number M 1 N0 1/9Assigned number originated and maintained by the sender

SEMANTIC: The data interchange control number GE02 in this trailer must beidentical to the same data element in the associated functional group header,GS06.


MAY 2006 C.9

IEAINTERCHANGE CONTROL TRAILER 005010X000 • 002 • IEAINTERCHANGE CONTROL TRAILER

SEGMENT DETAIL

IEA - INTERCHANGE CONTROL TRAILERX12 Segment Name: Interchange Control Trailer

X12 Purpose: To define the end of an interchange of zero or more functional groups andinterchange-related control segments

Segment Repeat: 1

Usage: REQUIRED

1000005 TR3 Example: IEA✽ 1✽ 000000905~

DIAGRAM

IEA01 I16 IEA02 I12

IEA ✽ Num of InclFunct Group ✽ Inter Ctrl

Number ~

M 1 N0 1/5 M 1 N0 9/9

ELEMENT DETAIL

USAGEREF.DES.


REQUIRED IEA01 I16 Number of Included Functional Groups M 1 N0 1/5A count of the number of functional groups included in an interchange

REQUIRED IEA02 I12 Interchange Control Number M 1 N0 9/9A control number assigned by the interchange sender


C.10 MAY 2006

D Change Summary This Implementation Guide defines X12N implementation 005010X223 of theHealth Care Claim: Institutional. It is based on version/release/subrelease005010 of the ASC X12 standards. The previous X12N implementation of theHealth Care Claim: Institutional was 004050X141, based on version/re-lease/subrelease 004050 of the ASC X12 standards.

Implementation of 005010X223 contains significant changes and clarifications. Itcan only be used with other trading partners who have also implemented005010X223. Below is a high-level description of the substantive changes fromthe previous version.

D.1 Global Changes1. All Situational Rules throughout this implementation guide have changed to

comply with ASC X12N implementation guide standards.

2. The guide contains many revisions to informational notes within the variousloops, segments and data elements. The revisions add explanatory text.

3. Billing Provider as well as all 2310x and 2420x provider loops contain in-struction on the use of the HIPAA National Provider Identifier (NPI) bothprior to, and after, the nationally mandated implementation date for thatidentifier. In instances where a provider identifier is reported, the NationalProvider Identifier is reported in NM109 data element with a NM108 quali-fier of XX. The EIN and SSN qualifiers have been removed from all providerrelated NM108 elements. Any secondary or proprietary identifiers are re-ported in the secondary identifier REF segments. For a more detailed expla-nation of NPI usage, see Section 1.10 National Provider Identifier Usagewithin the HIPAA 837 Transaction.

4. The G2 qualifier replaces program-specific codes such as 1A, Blue Cross;1B, Blue Shield; 1C, Medicare, 1D, Medicaid; 1H, Champus; etc. to desig-nate a proprietary identifier in all Secondary Identification provider seg-ments.

5. The following qualifiers have been revised to assign specific values in placeof generic values:

• The Provider Taxonomy Code has replaced the generic value of ZZ (Mutu-ally Defined) with the specific value of PXC (Health Care Provider Taxon-omy Code).

• The qualifier for the HIPAA Individual Patient Identifier has replaced thegeneric value of ZZ (Mutually Defined) with the specific value of II (Stand-ard Unique Health Identifier for each individual in the United States).

6. In order to report payer-specific provider identifiers, prior authorization, andreferral numbers for non-destination payers at the service line level, dataelement REF04 is used to indicate the payer associated with the identifier inREF01 and REF02.


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This implementation guide defines the X12N implementation of the 005010Xnnn of the Health Care Predetermination: Institutional. It is based on version 5010 of the X12 Standard. This is the first X12N implementation of the Health Care Predetermination: Institutional. Beginning with the next implementation, this section will summarize changes from the immediately preceding implementation.

7. Requirements for address segments (N3 and N4) have changed. The under-lying code sets for country codes and sub-country codes, as well as forpostal zones (ZIP Codes in the US) have been enhanced for greater interna-tional mailing uniformity.

8. References to “Insured” in notes and implementation names have changedto the more descriptive term “Subscriber”. See Section 1.5, Business Termi-nology and Section 1.4.3.2.2.2, Subscriber / Patient Hierarchical Level (HL)Segment for more information.

9. Changes have been made to support the HIPAA National Plan Identifier (Na-tional Plan ID). This identifier is accommodated in the following loops:

• Pay-to Plan Name, Loop ID-2010AC

• Payer Name, Loop ID-2010BB

• Other Payer Name, Loop ID-2330B

10. All Aliases have been removed from the guide.

D.2 Detailed Transaction ChangesFront Matter

ASC X12N implementation guide standards for the content and organization ofFront Matter sections have changed for this version. The items listed below arethose where significant changes have occurred. This list does not include sectionnumbering changes.

11. The explanation of COB reporting (Section 1.4.1) is enhanced and a cross-walk chart and examples are added to show how destination and non-desti-nation payer related information is reported on primary and secondaryclaims. The COB section includes several new supplemental explanations:

• COB claims generated from paper or proprietary remittance advices (Sec-tion 1.4.1.3).

• Medicaid subrogation claims (Section 1.4.1.5).

12. A section is added to specify the balancing requirements for the 837 trans-action (Section 1.4.4).

13. A section is added to explain allowed and approved amount reporting andcalculations (Section 1.4.5).

14. Business Terminology (Section 1.5) is expanded to include new definitionsof Bundling, Claim, Encounter, Inpatient, Outpatient, Pay-to-Plan Claims,and Unbundling. Other definitions were updated.

15. A section is added (Section 1.10) to describe the use of the NationalProvider Identifier (NPI) with the 837 transaction.

16. A section is added (Section 1.11) to explain the reporting of drug claims withthe 837 transaction.


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17. A section is added (Section 1.12) to address a number of additional 837 re-porting instructions, including:

• Individuals with one legal name,

• Rejecting claims based on the inclusion of situational data,

• Multiple REF segments with the same qualifier,

• Provider Tax ID’s,

• Claim and line redundant information,

• Inpatient and outpatient designation, and

• Trading partner acknowledgments.

Transaction Header

18. The value of the Implementation Reference Number (ST03) has changed to005010X223, which represents the guide ID for this implementation guide.

19. The Beginning of Hierarchical Transaction (BHT) segment includes exam-ples for a claim and an encounter.

Loop ID-2000A

20. Beginning with the 5010 version, the Billing Provider must be a health careor atypical service provider (as described in Section 1.10.1 Providers WhoAre Not Eligible for Enumeration).

21. The Pay-to Provider loop has been renamed and is now called the Pay-toAddress Name loop (Loop ID-2010AB). Its one and only purpose is to sup-ply an alternate location to send reimbursement.

22. Due to the change in function of the Pay-to Address Name loop, the onlypermitted value for the Provider Code (PRV01) in the Billing Provider Spe-cialty Information (PRV) segment is BI (Billing). The guide no longer sup-ports value PT (Pay-To).

23. The situational Rule for the Billing Provider Taxonomy (PRV) segment hasbeen expanded to enable non-individual taxonomies to be used.

24. The segment notes for the Foreign Currency Information (CUR) segmentnow include the instruction that all amounts reported in the transaction be ofthe currency named in the CUR segment. If there is no CUR segment, thenall amounts will be in US dollars.

Loop ID-2010AA

25. The Billing Provider loop contains no payer-specific provider identifiers.When it is necessary to send a payer-specific provider identifier, it must besent in either the Payer Name loop (Loop ID-2010BB) or the Other PayerName loop (Loop ID-2330B).

26. The only provider identifiers allowed in the Billing Provider loop are:

• the NPI

• the provider’s taxpayer id


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27. The Billing Provider Name segment contains the NPI, which is Situational.

28. The Billing Provider Address must be a street address. Other types of mail-ing addresses for the Billing Provider (such as a Post Office Box or a LockBox) must be sent in the Pay-To Address Name loop.

29. The Billing Provider Secondary Identification Number segment has beenchanged to be the Billing Provider Tax Identification segment.

30. The Billing Provider Tax Identification (REF) segment is required and con-tains the provider’s taxpayer identifier to be used for 1099 reporting pur-poses.

31. The Claim Submitter Credit/Debit Card Information (REF) segment hasbeen deleted.

32. The Billing Provider Contact Name (PER02) is Required in the first iterationof the Billing Provider Contact Information segment. If a second iteration ofthe segment is sent, PER02 is Not Used.

Loop ID-2010AB

33. The Pay-To Address Name loop replaces the Pay-To Provider Name loop.Its sole purpose is to supply an alternate location to send reimbursement.There are no names and no identifiers in the Pay-To Address Name loop.

34. The Pay-To Provider Secondary Identification Number (REF) segment hasbeen removed.

Loop ID-2010AC

35. The usage of the Pay-to Plan Name loop has expanded and is no longerlimited to Medicaid subrogation.

36. The qualifier in NM101 has been changed to no longer use the genericvalue ZZ (Mutually Defined) in favor of the more specific value PE (Payee).

37. The Pay-to Plan secondary REF segments have been “flattened”. There arenow two distinct segments, each with a repeat count of one. The segmentsare the Pay-to Plan Secondary Identification segment and the Pay-to PlanTax Identification Number segment.

Loop ID-2000B

38. The Subscriber / Patient hierarchy has changed to follow the same princi-ples used in other HIPAA transactions, such as Eligibility Request/Re-sponse and Claim Status Inquiry/Response. The basic principles are as fol-lows:

• If the patient has a unique identifier assigned by the destination payer inLoop ID-2010BB, then the patient is considered to be the subscriber andis sent in the Subscriber loop (Loop ID-2000B) and the Patient Hierarchi-cal Level (Loop ID-2000C) is not used.

• If the patient is different than the subscriber and the patient does not havea unique identifier, then the subscriber information is sent in Loop ID-2000B and the patient information is sent in Loop ID-2000C.


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39. There are new values for the Payer Responsibility Sequence Number Code(SBR01). The new values support sequencing of up to 11 payers. The newvalues also include a value of U (Unknown) to be used in certain payer-to-payer COB situations.

40. The Situational Rule for the Subscriber Group Name (SBR04) has changed.

41. The list of valid values for the Claim Filing Indicator Code (SBR09) haschanged.

Loop ID-2010BA

42. The Subscriber Primary Identifier and its qualifier (NM108 and NM109) arenow required.

43. The Situational Rule for the Subscriber Address segments (N3 and N4) haschanged.

44. The Situational Rule for the Subscriber Demographic Information segment(DMG) has changed.

45. The Repeat Count for the Subscriber Secondary Identification (REF) seg-ment has decreased to one. The only permitted value for the SubscriberSecondary Identification (REF) segment is the subscriber’s Social SecurityNumber (qualifier SY).

Loop ID-2010BB

46. By adding an informational note to the Payer Name segment, the usage ofthis segment and loop now explicitly supports designating a repricer as thedestination payer.

47. The element notes for the qualifier for the Payer Identifier (NM108/NM109)now contain specific instructions on when to use the HIPAA National PlanID (value XV) vs. when to use the generic Payer Identifier (value PI).

48. Loop ID-2010BB (Payer Name) now contains the Billing Provider Secon-dary Information (REF) segment. This new segment contains provider identi-fiers that were formerly sent in the Billing Provider loop.

Loop ID-2010BC

49. Loop ID-2010BC (Credit/Debit Card Holder Name) has been deleted.

Loop ID-2000C

50. The Situational Rule for the Patient Hierarchical Level has changed in sup-port of the revised Subscriber / Patient hierarchy. The loop is required onlywhen the patient is not the subscriber and the patient does not have aunique identifier assigned by the destination payer. In this case, the patientcan only be identified when associated with the subscriber.

Loop ID-2010CA

51. The Patient Primary Identifier and associated qualifier (NM108/NM109) arenow Not Used.


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52. The Patient Secondary Identification (REF) segment has been deleted.

Loop ID-2300

53. The Total Claim Charge Amount (CLM02) now explicitly states that it mustbe the sum of the service line charge amounts (sum of the SV203’s.)

54. CLM07 has changed from Situational to Required.

55. The element note for the Provider Accept Assignment Code (CLM07) haschanged to be more specific in its usage for Medicare claims and non-Medi-care claims. Value P (Patient Refuses to Assign Benefits) has been re-moved.

56. A new value has been added to CLM08, the Benefits Assignment Certifica-tion Indicator. The new value is W (Not Applicable), which means that thepatient has refused to assign benefits to the provider. In the previous ver-sion, CLM07 = P carried this message.

57. The usage of values in the Release of Information Code (CLM09) has beenclarified to coincide with Privacy legislation.

58. This version has added a new date segment as the Repricer ReceivedDate.

59. Available values in the Attachment Report Type Code (PWK01) have beenexpanded.

60. The Attachment Transmission Code (PWK02) has added new value FT(File Transfer) to designate that the attachment is available from an attach-ment warehouse (vendor).

61. The Situational Rule for both PWK05 and PWK06 has changed to supportPWK02 = FT.

62. The maximum field length for the Attachment Control Number (PWK06) isnow 50 characters.

63. The Credit / Debit Card - Maximum Amount (AMT) segment has been re-moved.

64. The Situational Rule for the Service Authorization Exception Code (REF)segment has been clarified.

65. The segment notes for the Payer Claim Control Number (REF) segmenthave been clarified.

66. The Prior Authorization or Referral Number (REF) segment is now two dis-tinct segments: the Referral Number segment; and the Prior Authorizationsegment. The qualifiers did not change.

67. The Repriced Claim Number (REF) and the Adjusted Repriced Claim Num-ber (REF) segments have been added to the 2300 loop.


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68. The Claim Identifier for Transmission Intermediaries is the new name for theClaim Identification Number for Clearinghouses and Other Transmission In-termediaries segment. The qualifier (REF01 = D9) did not change.

69. The Auto Accident State (REF) segment has been added.

70. The Situational Rule has been clarified for the File Information (K3) seg-ment. Segment notes explain the process for applying for an exception tobe allowed to use the segment.

71. In all diagnosis code related (HI) segments, an additional qualifier has beenadded to support ICD-10-CM Diagnosis Codes (if allowed under HIPAA).

72. The Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis In-formation (HI) segment has been split into separate HI segments for:

• Principal Diagnosis;

• Admitting Diagnosis;

• Patient’s Reason for Visit; and,

• External Cause of Injury.

73. Up to three Patient Reason for Visit values may now be reported per claim.

74. Up to twelve External Cause of Injury values may now be reported perclaim.

75. A Present on Admission Indicator has been added to the Other Diagnosis In-formation (HI) segment.

76. The Situational Rule for the Principal Procedure Information (HI) segmenthas been revised so that a claim level procedure is only reported on inpa-tient claims. Further, the segment is only used when a procedure was per-formed.

77. The Situational Rule for the Other Procedure Information (HI) segment hasbeen revised so that a other procedures are only reported on inpatientclaims.

78. The qualifier for HCPCS procedure codes has been removed from allow-able values in the Principal Procedure Information and Other Procedure In-formation (HI) segments.

79. The qualifier for Advanced Billing Concepts Codes has been added to thePrincipal Procedure Information (HI) segment.

80. The Situational Rule for the claim-level Claim Pricing / Repricing Informa-tion (HCP) segment has been clarified. The Situational Rules for the dataelements within the segment have also been clarified.


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Loop ID-2305

81. The Home Health Care Plan Information loop (Loop ID-2305) including theHome Health Care Plan Information (CR7) and Health Care Services Deliv-ery (HSD) segments have been removed.

Loop ID-2310A

82. The Attending Physician Name (NM1) segment has been renamed to At-tending Provider Name.

83. The Situational Rule for the claim-level Attending Provider loop has beenclarified.

84. A TR3 Note has been added to the Attending Physician Name (NM1) seg-ment to define this provider role.

85. The Attending Provider must be a person. (Loop ID-2310A|NM102 must bea ’1’.)

86. The only identifier allowed in the Attending Provider Name segment(NM108 and NM109) is the National Provider Identifier (NPI). The identifierhas a usage of Situational.

87. The segment repeat for the Attending Provider Secondary Identification(REF) segment has been reduced to 4.

88. The list of valid qualifiers for the Attending Provider Secondary Identifier(Loop ID-2310A | REF01) now contains only 0B (State License Number),1G (Provider UPIN Number), G2 (Provider Commercial Number), and LU(Location Number). The specific values such as 1B (Blue Shield ProviderNumber), 1D (Medicaid Provider Number) etc. have been removed. In theirplace, use G2.

Loop ID-2310B

89. The Situational Rule for the claim-level Operating Physician loop has beenclarified.

90. The only identifier allowed in the Operating Physician Name segment(NM108 and NM109) is the National Provider Identifier (NPI). The identifierhas a usage of Situational.

91. The segment repeat for the Operating Physician Secondary Identification(REF) segment has been reduced to 4.

92. The list of valid qualifiers for the Operating Physician Secondary Identifier(Loop ID-2310A|REF01) now contains only 0B (State License Number), 1G(Provider UPIN Number), G2 (Provider Commercial Number) and LU (Loca-tion Number). The specific values such as 1B (Blue Shield Provider Num-ber), 1D (Medicaid Provider Number) etc. have been removed. In theirplace, use G2.


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Loop ID-2310C through Loop ID-2310F

93. Other Provider Name loop (Loop ID-2310C in 004050X141) has been de-leted. This deleted loop, along with the addition of several new providerloops, has resulted in the following 2310 loop changes.

• Other Provider Name is removed. Loop ID-2310C is redefined to OtherOperating Physician Name.

• New Loop ID-2310D for Rendering Provider Name is added.

• Service Facility Name - Loop ID-2310E has loop name expanded to Serv-ice Facility Location Name.

• New Loop ID-2310F for Referring Provider Name is added.

Loop ID-2310E

94. The Situational Rule for the claim-level Service Facility Location Name loophas been clarified.

95. The only identifier allowed in the Service Facility Location Name segment(NM108 and NM109) is the National Provider Identifier (NPI). The identifierhas a usage of Situational.

96. The Entity Identifier Code in the Service Facility Location Name segmentmust be ’77’.

97. The Repeat Count for the Service Facility Location Secondary Identificationsegment is now three.

98. The list of valid qualifiers for the Service Facility Location Name SecondaryIdentifier (Loop ID-2310A | REF01) now contains only 0B (State LicenseNumber), G2 (Provider Commercial Number) and LU (Location Number).The specific values such as 1B (Blue Shield Provider Number), 1D (Medi-caid Provider Number) etc. have been removed. In their place, use G2.

Loop ID-2320

99. There are new values for the Payer Responsibility Sequence Number Code(SBR01). The new values support sequencing of up to 11 payers.

100. The Situational Rule for the Subscriber Group Name (SBR04) has changed.

101. The list of valid values for the Claim Filing Indicator Code (SBR09) haschanged.

102. The segment notes and Situational Rule for the Claim Adjustment (CAS)segment have been clarified.

103. The Situational Rules for the various elements in the CAS segment havebeen clarified.

104. The COB Total Allowed Amount (AMT) segment in Loop ID-2320 has beenremoved.


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105. The Remaining Patient Liability (AMT) segment has been added to Loop ID-2320.

106. The COB Total Non-Covered Amount (AMT) segment has been added toLoop ID-2320.

107. The Other Insured Demographic Information (DMG) segment has been re-moved.

108. A new value has been added to OI03 (Benefits Assignment Certification Indi-cator). The new value is W (Not Applicable), which means that the patienthas refused to assign benefits to the provider.

109. The Situational Rule for the Inpatient Adjudication Information (MIA) seg-ment has been clarified.

110. The Situational Rule for the Outpatient Adjudication Information (MOA) seg-ment has been clarified.

Loop ID-2330A

111. The Situational Rule for the Other Subscriber has been clarified.

112. The Repeat Count for the Subscriber Secondary Identification (REF) seg-ment has decreased from three to two.

113. The only permitted value for the Subscriber Secondary Identification (REF)segment is the subscriber’s Social Security Number (qualifier SY).

Loop ID-2330B

114. The element notes for the Other Payer Primary Identifier (Loop ID-2330B |NM108-NM109) contain instructions for using the HIPAA National Plan ID,when issued.

115. The Claim Adjudication Date (DTP) segment has been renamed to ClaimCheck or Remittance Date segment.

116. The Other Payer Secondary Identification and Reference Number (REF)segment and the Other Payer Prior Authorization or Referral Number (REF)segment have been split into the following separate segments:

• Other Payer Secondary Identifier;

• Other Payer Prior Authorization Number;

• Other Payer Referral Number; and,

• Other Payer Claim Control Number.

117. The Other Payer Claim Adjustment Indicator (REF) segment have beenadded.

118. The Other Payer Patient Information loop (formerly Loop ID-2330C) hasbeen removed. If the payer in Loop ID-2330B has assigned a unique identi-fier to the patient, then the patient must be sent in the Other Subscriberloop.


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Loop ID-2330C through Loop ID-2330I

119. The removal of the Other Payer Patient Information loop, and the additionof several new 2330 loops results in the following loop name changes.These changes are listed showing the 004050X141 Loop ID first followedby the Loop ID as named within this implementation.

• Other Payer Attending Provider - Loop ID-2330D moved to Loop ID-2330C.

• Other Payer Operating Physician - Loop ID-2330E moved to Loop ID-2330D.

• Other Payer Other Provider - Loop ID-2330F is removed.

• Other Payer Service Facility Location - Loop ID-2330H is moved to LoopID-2330F.

• Other Payer Other Operating Physician - New Loop ID-2330E.

• Other Payer Rendering Provider - New Loop ID-2330G.

• Other Payer Referring Provider - New Loop ID-2330H.

• Other Payer Billing Provider - New Loop ID-2330I.

120. The Other Payer Patient Information loop (Loop ID-2330C) has been re-moved. All remaining 2330x loops have been renumbered.

121. Loop ID-2330F (Other Payer Billing Provider) has been added.

122. Loop ID-2330G (Other Payer Service Facility Location) has been added.

123. Loop ID-2330H (Other Payer Assistant Surgeon) has been added.

Loop ID-2400

124. The Procedure Code Description (SV202-7) has been changed from NotUsed to Situational.

125. The usage of the Line Item Charge Amount (SV203) has been clarified. Theamount is inclusive of the provider’s base charge and any applicable taxamounts reported in the line’s tax amount (AMT) segments.

126. The maximum size of the Service Unit Count (SV205) is set at 8 digits.

127. The Unit Rate (SV206) is changed to Not Used.

128. Available values in the Attachment Report Type Code (PWK01) have beenexpanded.

129. The Attachment Transmission Code (PWK02) has added new value FT(File Transfer) to designate that the attachment is available from an attach-ment warehouse (vendor).

130. The Situational Rule for both PWK05 and PWK06 has changed to supportPWK02 = FT.


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131. The maximum field length for the Attachment Control Number (PWK06) isnow 50 characters.

132. The name of the Service Line Date (DTP) segment has changed to Date -Service Date.

133. The usage notes for the Line Item Control Number (REF) segment havebeen clarified.

134. The Situational Rule and usage notes for the Service Tax Amount and Facil-ity Tax Amount (AMT) segments have been clarified along with a reminderthat the Line Item Charge Amount (SV203) must include amounts reportedin the Service and Facility Tax Amounts.

135. Added Third Party Organization Notes (NTE) segment.

136. The usage of the Line Pricing/Repricing Information (HCP) segment hasbeen clarified.

137. The listed values in Product or Service ID Qualifier (HCP09) have beenmodified to be in sync with the qualifiers listed in SV202-1.

Loop ID-2410

138. The usage of the Drug Quantity (CTP) segment has been changed from Si-tuational to Required. Notes were deleted.

139. The name of the Prescription Number (REF) segment has been changed toPrescription or Compound Drug Association Number.

140. The Situational Rule and TR3 Notes of the Prescription or Compound DrugAssociation Number (REF) segment have been clarified.

141. Added the qualifier VY (Link Sequence Number) to the Prescription or Com-pound Drug Association Number (REF) segment.

Loop ID-2420A through Loop ID-2420D

142. Attending Physician Name loop (Loop ID-2420A in the 004050X141) andthe Other Provider Name loop (Loop ID-2420C in the 004050X141) havebeen deleted. The removal of these loops, and the addition of several new2420 loops results in the following loop name changes. These changes arelisted showing the 004050X141 Loop ID first followed by the Loop ID asnamed within this implementation.

• Attending Physician - Loop ID-2420A is removed.

• Operating Physician - Loop ID-2420B moved to Loop ID-2420A.

• Other Operating Physician - New Loop ID-2420B.

• Other Provider - Loop ID-2420C is removed.

• Rendering Provider - New Loop ID-2420C.

• Referring Provider - New Loop ID-2420D.


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143. The Secondary Identifier (REF) segments in the 2420 service line providerloops now allow identification of a specific payer (the destination payernamed in Loop ID-2010BB or a specified payer from the Other Payer loop(Loop ID-2330B). If the identifier belongs to the destination payer, then com-posite REF04 is not used. If the identifier belongs to a specific non-destina-tion payer, then REF04 indicates the specific non-destination payer.

Loop ID-2430

144. The Situational Rule and the usage notes for the Line Adjudication Informa-tion loop have been clarified.

145. Crosswalk references to specific elements in the ASC X12 835 Payment /Remittance Advice transaction have been removed.

146. SVD01 element note of the Line Adjudication Information (SVD) segmentwas clarified.

147. Since there is now a specific qualifier available, the generic qualifier ZZ forthe Product or Service ID Qualifier (SVD03-1) has been replaced by thespecific qualifier ER (Jurisdiction Specific Procedure and Supply Codes), asdefined by Code Source 576.

148. Added element note to the Paid Service Unit Count SVD05 of the Line Adju-dication Information (SVD) segment to indicate a maximum length of 8 dig-its excluding the decimal. When decimal used, maximum digits allowed tothe right of decimal is three.

149. The usage notes for SVD06 Bundled Line Number have been clarified.

150. The segment name for the CAS segment changed from Service Line Adjust-ment to the more descriptive Line Adjustment.

151. The segment name for the DTP segment changed from Service Adjudica-tion Date to the more descriptive Line Check or Remittance Date.

152. The Remaining Patient Liability (AMT) segment has been added.


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D.14 MAY 2006

E Data Element Glossary

E.1 Data Element Name IndexThis section contains an alphabetic listing of data elements used in this im-plementation guide. Consult the X12N Data Element Dictionary for a com-plete list of all X12N Data Elements. Data element names in normal type aregeneric ASC X12 names. Italic type indicates a health care industry definedname.

Payment DateDate of payment.

277D | 2200D | SPA12 | C001-2 | 373 .............. 156

Adjudication or Payment DateDate of payment or denial determination byprevious payer.D | 2330B | DTP03 | - | 1251 .............389D | 2430 | DTP03 | - | 1251 .............486

ADJUSTED REPRICED CLAIM REFERENCE NUMBER

Adjusted Repriced ClaimReference NumberIdentification number, assigned by a repricingorganization, to identify an adjusted claim.D | 2300 | REF02 | - | 127 ...............168

ADJUSTED REPRICED LINE ITEM REFERENCE NUMBER

Adjusted Repriced Line ItemReference NumberIdentification number of an adjusted repricedline item adjusted from an original amount.D | 2400 | REF02 | - | 127 ...............438

ADJUSTMENT AMOUNT

Adjustment AmountAdjustment amount for the associated reasoncode.D | 2320 | CAS03 | - | 782 ...............360D | 2320 | CAS06 | - | 782 ...............360D | 2320 | CAS09 | - | 782 ...............361D | 2320 | CAS12 | - | 782 ...............362D | 2320 | CAS15 | - | 782 ...............362D | 2320 | CAS18 | - | 782 ...............363D | 2430 | CAS03 | - | 782 ...............482D | 2430 | CAS06 | - | 782 ...............482D | 2430 | CAS09 | - | 782 ...............483D | 2430 | CAS12 | - | 782 ...............483D | 2430 | CAS15 | - | 782 ...............484D | 2430 | CAS18 | - | 782 ...............485

ADJUSTMENT QUANTITY

Adjustment QuantityNumeric quantity associated with the relatedreason code for coordination of benefits.D | 2320 | CAS04 | - | 380 .............. 360D | 2320 | CAS07 | - | 380 .............. 361D | 2320 | CAS10 | - | 380 .............. 361D | 2320 | CAS13 | - | 380 .............. 362D | 2320 | CAS16 | - | 380 .............. 362D | 2320 | CAS19 | - | 380 .............. 363D | 2430 | CAS04 | - | 380 .............. 482D | 2430 | CAS07 | - | 380 .............. 482D | 2430 | CAS10 | - | 380 .............. 483D | 2430 | CAS13 | - | 380 .............. 484D | 2430 | CAS16 | - | 380 .............. 484D | 2430 | CAS19 | - | 380 .............. 485

ADJUSTMENT REASON CODE

Adjustment Reason CodeCode that indicates the reason for theadjustment.D | 2320 | CAS02 | - | 1034 ............ 360D | 2320 | CAS05 | - | 1034 ............ 360D | 2320 | CAS08 | - | 1034 ............ 361D | 2320 | CAS11 | - | 1034 ............ 361D | 2320 | CAS14 | - | 1034 ............ 362D | 2320 | CAS17 | - | 1034 ............ 363D | 2430 | CAS02 | - | 1034 ............ 482D | 2430 | CAS05 | - | 1034 ............ 482D | 2430 | CAS08 | - | 1034 ............ 483D | 2430 | CAS11 | - | 1034 ............ 483D | 2430 | CAS14 | - | 1034 ............ 484D | 2430 | CAS17 | - | 1034 ............ 484

ADMISSION DATE AND HOUR

Admission Date and HourThe date and time of the admission to thefacility.D | 2300 | DTP03 | - | 1251 ............ 151

ADMISSION SOURCE CODE

H=Header, D=Detail, S=Summary

Loop ID

Segment ID/Reference Designator

Composite ID-Sequence

Data Element Number

Page Number

Name

Definition

Transaction Set ID

Locator Key


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Add Predetermination of Benefits Code: "Code indicating that the associated claim is a predetermination of benefits request rather than a claim or encounter." (existing definition in the x224 guide)

Admission Source CodeCode indicating the source of this admission.D | 2300 | CL102 | - | 1314 ............ 153

ADMISSION TYPE CODE

Admission Type CodeCode indicating the priority of this admission.D | 2300 | CL101 | - | 1315 ............ 153

ADMITTING DIAGNOSIS CODE

Admitting Diagnosis CodeThe diagnosis code describing the patient’sdiagnosis at the time of admission.D | 2300 | HI01 | C022-2 | 1271 ............ 188

AMOUNT QUALIFIER CODE

Amount Qualifier CodeCode to qualify amount.D | 2300 | AMT01 | - | 522 .............. 160D | 2320 | AMT01 | - | 522 .............. 364D | 2320 | AMT01 | - | 522 .............. 365D | 2320 | AMT01 | - | 522 .............. 366D | 2400 | AMT01 | - | 522 .............. 439D | 2400 | AMT01 | - | 522 .............. 440D | 2430 | AMT01 | - | 522 .............. 487

ASSIGNED NUMBER

Assigned NumberNumber assigned for differentiation within atransaction set.D | 2400 | LX01 | - | 554 .............. 423

ASSIGNMENT OR PLAN PARTICIPATION CODE

Assignment or PlanParticipation CodeAn indication, used by a health plan, that theprovider does or does not accept assignment ofbenefits.D | 2300 | CLM07 | - | 1359 ............ 146

ATTACHMENT CONTROL NUMBER

Attachment Control NumberIdentification number of attachment related tothe claim.D | 2300 | PWK06 | - | 67 ................ 157D | 2400 | PWK06 | - | 67 ................ 432

ATTACHMENT REPORT TYPE CODE

Attachment Report Type CodeCode to specify the type of attachment that isrelated to the claim.D | 2300 | PWK01 | - | 755 .............. 155D | 2400 | PWK01 | - | 755 .............. 430

ATTACHMENT TRANSMISSION CODE

Attachment Transmission CodeCode defining timing, transmission method orformat by which an attachment report is to besent or has been sent.D | 2300 | PWK02 | - | 756 .............. 156D | 2400 | PWK02 | - | 756 .............. 431

ATTENDING PROVIDER FIRST NAME

Attending Provider First NameFirst Name of the provider responsible for thecare of the patient.D | 2310A | NM104 | - | 1036 ............ 320

ATTENDING PROVIDER LAST NAME

Attending Provider Last NameLast Name of the provider responsible for thecare of the patient.D | 2310A | NM103 | - | 1035 ............ 320

ATTENDING PROVIDER MIDDLE NAME OR INITIAL

Attending Provider MiddleName or InitialMiddle name or initial of the providerresponsible for care of the patient.D | 2310A | NM105 | - | 1037 ............ 320

ATTENDING PROVIDER NAME SUFFIX

Attending Provider Name SuffixSuffix to the name of the provider responsiblefor the care of the patient.D | 2310A | NM107 | - | 1039 ............ 320

ATTENDING PROVIDER PRIMARY IDENTIFIER

Attending Provider PrimaryIdentifierPrimary identifier for the provider responsible forthe care of the patient.D | 2310A | NM109 | - | 67 ................ 321

ATTENDING PROVIDER SECONDARY IDENTIFIER

Attending Provider SecondaryIdentifierAdditional identifier for the provider responsiblefor the care of the patient.D | 2310A | REF02 | - | 127 .............. 325

AUTO ACCIDENT STATE OR PROVINCE CODE

Auto Accident State orProvince CodeState or Province where auto accident occurred.D | 2300 | REF02 | - | 127 .............. 172

BENEFITS ASSIGNMENT CERTIFICATION INDICATOR

Benefits AssignmentCertification IndicatorA code showing whether the provider has asigned form authorizing the third party payer topay the provider.D | 2300 | CLM08 | - | 1073 ............ 146D | 2320 | OI03 | - | 1073 ............ 367

BILLING NOTE TEXT

Billing Note TextFree-form text providing additional informationabout the bill or claim being submitted.D | 2300 | NTE02 | - | 352 .............. 180

BILLING PROVIDER ADDRESS LINE

Billing Provider Address LineAddress line of the billing provider or billingentity address.D | 2010AA | N301 | - | 166 ................ 87D | 2010AA | N302 | - | 166 ................ 87

BILLING PROVIDER CITY NAME

Billing Provider City NameCity of the billing provider or billing entityD | 2010AA | N401 | - | 19 .................. 88

BILLING PROVIDER CONTACT NAME


E.2 MAY 2006

Billing Provider Contact NamePerson at billing organization to contactregarding the billing transaction.D | 2010AA | PER02 | - | 93 .................. 92

BILLING PROVIDER IDENTIFIER

Billing Provider IdentifierIdentification number for the provider ororganization in whose name the bill is submittedand to whom payment should be made.D | 2010AA | NM109 | - | 67 .................. 86

BILLING PROVIDER ORGANIZATIONAL NAME

Billing Provider OrganizationalNameOrganization name of the entity billing forservices.D | 2010AA | NM103 | - | 1035 .............. 85

BILLING PROVIDER POSTAL ZONE OR ZIP CODE

Billing Provider Postal Zone orZIP CodePostal zone code or ZIP code for the provider orbilling entity billing for services.D | 2010AA | N403 | - | 116................. 89

BILLING PROVIDER SECONDARY IDENTIFIER

Billing Provider SecondaryIdentifierSecondary identification number for the provideror organization in whose name the bill issubmitted and to whom payment should bemade.D | 2010BB | REF02 | - | 127 .............. 130

BILLING PROVIDER STATE OR PROVINCE CODE

Billing Provider State orProvince CodeState or province for provider or billing entitybilling for services.D | 2010AA | N402 | - | 156 ................ 89

BILLING PROVIDER TAX IDENTIFICATION NUMBER

Billing Provider TaxIdentification NumberTax identification number for the provider ororganization in whose name the bill is submittedand to whom payment should be made.D | 2010AA | REF02 | - | 127 ................ 90

BUNDLED LINE NUMBER

Bundled Line NumberIdentification of line item bundled by payer inpayment of benefits.D | 2430 | SVD06 | - | 554 .............. 479

CERTIFICATION CONDITION CODE APPLIES INDICATOR

Certification Condition CodeApplies IndicatorCode indicating whether or not the conditioncodes apply to the patient or another entity.D | 2300 | CRC02 | - | 1073 ............ 182

CLAIM ADJUSTMENT GROUP CODE

Claim Adjustment Group CodeCode identifying the general category ofpayment adjustment.D | 2320 | CAS01 | - | 1033 ............ 360D | 2430 | CAS01 | - | 1033 ............ 481

CLAIM DRG AMOUNT

Claim DRG AmountTotal of Prospective Payment System operatingand capital amounts for this claim.D | 2320 | MIA04 | - | 782 .............. 370

CLAIM DISPROPORTIONATE SHARE AMOUNT

Claim Disproportionate ShareAmountSum of operating capital disproportionate shareamounts for this claim.D | 2320 | MIA06 | - | 782 .............. 370

CLAIM FILING INDICATOR CODE

Claim Filing Indicator CodeCode identifying type of claim or expectedadjudication process.D | 2000B | SBR09 | - | 1032 .............110D | 2320 | SBR09 | - | 1032 ............ 356

CLAIM FREQUENCY CODE

Claim Frequency CodeCode specifying the frequency of the claim. Thisis the third position of the Uniform Billing ClaimForm Bill Type.D | 2300 | CLM05 | C023-3 | 1325 ............ 145

CLAIM IDENTIFIER

Claim IdentifierIdentifies type of claims in this transaction.H | | BHT06 | - | 640 ................ 69

CLAIM INDIRECT TEACHING AMOUNT

Claim Indirect Teaching AmountTotal of operating and capital indirect teachingamounts for this claim.D | 2320 | MIA18 | - | 782 .............. 372

CLAIM MSP PASS-THROUGH AMOUNT

Claim MSP Pass-throughAmountInterim cost pass-though amount used todetermine Medicare Secondary Payer liability.D | 2320 | MIA07 | - | 782 .............. 370

CLAIM NOTE TEXT

Claim Note TextNarrative text providing additional informationrelated to the claim.D | 2300 | NTE02 | - | 352 .............. 179

CLAIM PPS CAPITAL AMOUNT

Claim PPS Capital AmountTotal Prospective Payment System (PPS)capital amount payable for this claim as outputby PPS PRICER.D | 2320 | MIA08 | - | 782 .............. 370

CLAIM PPS CAPITAL OUTLIER AMOUNT


MAY 2006 E.3

Claim PPS Capital OutlierAmountTotal Prospective Payment System capital dayor cost outlier payable for this claim, excludingoperating outlier amount.D | 2320 | MIA17 | - | 782 .............. 372

CLAIM PAYMENT REMARK CODE

Claim Payment Remark CodeCode identifying the remark associated with thepayment.D | 2320 | MIA05 | - | 127 .............. 370D | 2320 | MIA20 | - | 127 .............. 372D | 2320 | MIA21 | - | 127 .............. 373D | 2320 | MIA22 | - | 127 .............. 373D | 2320 | MIA23 | - | 127 .............. 373D | 2320 | MOA03 | - | 127 .............. 375D | 2320 | MOA04 | - | 127 .............. 375D | 2320 | MOA05 | - | 127 .............. 375D | 2320 | MOA06 | - | 127 .............. 375D | 2320 | MOA07 | - | 127 .............. 375

CODE LIST QUALIFIER CODE

Code List Qualifier CodeCode identifying a specific industry code list.D | 2300 | HI01 | C022-1 | 1270 ............ 184D | 2300 | HI01 | C022-1 | 1270 ............ 188D | 2300 | HI01 | C022-1 | 1270 ............ 190D | 2300 | HI02 | C022-1 | 1270 ............ 191D | 2300 | HI03 | C022-1 | 1270 ............ 192D | 2300 | HI01 | C022-1 | 1270 ............ 194D | 2300 | HI02 | C022-1 | 1270 ............ 196D | 2300 | HI03 | C022-1 | 1270 ............ 198D | 2300 | HI04 | C022-1 | 1270 ............ 200D | 2300 | HI05 | C022-1 | 1270 ............ 202D | 2300 | HI06 | C022-1 | 1270 ............ 204D | 2300 | HI07 | C022-1 | 1270 ............ 206D | 2300 | HI08 | C022-1 | 1270 ............ 208D | 2300 | HI09 | C022-1 | 1270 ............ 210D | 2300 | HI10 | C022-1 | 1270 ............ 212D | 2300 | HI11 | C022-1 | 1270 ............ 214D | 2300 | HI12 | C022-1 | 1270 ............ 216D | 2300 | HI01 | C022-1 | 1270 ............ 218D | 2300 | HI01 | C022-1 | 1270 ............ 221D | 2300 | HI02 | C022-1 | 1270 ............ 222D | 2300 | HI03 | C022-1 | 1270 ............ 224D | 2300 | HI04 | C022-1 | 1270 ............ 225D | 2300 | HI05 | C022-1 | 1270 ............ 227D | 2300 | HI06 | C022-1 | 1270 ............ 228D | 2300 | HI07 | C022-1 | 1270 ............ 230D | 2300 | HI08 | C022-1 | 1270 ............ 231D | 2300 | HI09 | C022-1 | 1270 ............ 233D | 2300 | HI10 | C022-1 | 1270 ............ 234D | 2300 | HI11 | C022-1 | 1270 ............ 236D | 2300 | HI12 | C022-1 | 1270 ............ 237D | 2300 | HI01 | C022-1 | 1270 ............ 240D | 2300 | HI01 | C022-1 | 1270 ............ 243D | 2300 | HI02 | C022-1 | 1270 ............ 244D | 2300 | HI03 | C022-1 | 1270 ............ 245D | 2300 | HI04 | C022-1 | 1270 ............ 246D | 2300 | HI05 | C022-1 | 1270 ............ 248D | 2300 | HI06 | C022-1 | 1270 ............ 249D | 2300 | HI07 | C022-1 | 1270 ............ 250D | 2300 | HI08 | C022-1 | 1270 ............ 251D | 2300 | HI09 | C022-1 | 1270 ............ 253D | 2300 | HI10 | C022-1 | 1270 ............ 254D | 2300 | HI11 | C022-1 | 1270 ............ 255D | 2300 | HI12 | C022-1 | 1270 ............ 256D | 2300 | HI01 | C022-1 | 1270 ............ 258D | 2300 | HI02 | C022-1 | 1270 ............ 259D | 2300 | HI03 | C022-1 | 1270 ............ 260D | 2300 | HI04 | C022-1 | 1270 ............ 261

D | 2300 | HI05 | C022-1 | 1270 ............ 262D | 2300 | HI06 | C022-1 | 1270 ............ 263D | 2300 | HI07 | C022-1 | 1270 ............ 264D | 2300 | HI08 | C022-1 | 1270 ............ 265D | 2300 | HI09 | C022-1 | 1270 ............ 266D | 2300 | HI10 | C022-1 | 1270 ............ 267D | 2300 | HI11 | C022-1 | 1270 ............ 268D | 2300 | HI12 | C022-1 | 1270 ............ 269D | 2300 | HI01 | C022-1 | 1270 ............ 271D | 2300 | HI02 | C022-1 | 1270 ............ 272D | 2300 | HI03 | C022-1 | 1270 ............ 273D | 2300 | HI04 | C022-1 | 1270 ............ 274D | 2300 | HI05 | C022-1 | 1270 ............ 275D | 2300 | HI06 | C022-1 | 1270 ............ 276D | 2300 | HI07 | C022-1 | 1270 ............ 277D | 2300 | HI08 | C022-1 | 1270 ............ 278D | 2300 | HI09 | C022-1 | 1270 ............ 279D | 2300 | HI10 | C022-1 | 1270 ............ 280D | 2300 | HI11 | C022-1 | 1270 ............ 281D | 2300 | HI12 | C022-1 | 1270 ............ 282D | 2300 | HI01 | C022-1 | 1270 ............ 284D | 2300 | HI02 | C022-1 | 1270 ............ 285D | 2300 | HI03 | C022-1 | 1270 ............ 286D | 2300 | HI04 | C022-1 | 1270 ............ 287D | 2300 | HI05 | C022-1 | 1270 ............ 287D | 2300 | HI06 | C022-1 | 1270 ............ 288D | 2300 | HI07 | C022-1 | 1270 ............ 289D | 2300 | HI08 | C022-1 | 1270 ............ 290D | 2300 | HI09 | C022-1 | 1270 ............ 290D | 2300 | HI10 | C022-1 | 1270 ............ 291D | 2300 | HI11 | C022-1 | 1270 ............ 292D | 2300 | HI12 | C022-1 | 1270 ............ 293D | 2300 | HI01 | C022-1 | 1270 ............ 294D | 2300 | HI02 | C022-1 | 1270 ............ 295D | 2300 | HI03 | C022-1 | 1270 ............ 296D | 2300 | HI04 | C022-1 | 1270 ............ 297D | 2300 | HI05 | C022-1 | 1270 ............ 297D | 2300 | HI06 | C022-1 | 1270 ............ 298D | 2300 | HI07 | C022-1 | 1270 ............ 299D | 2300 | HI08 | C022-1 | 1270 ............ 300D | 2300 | HI09 | C022-1 | 1270 ............ 300D | 2300 | HI10 | C022-1 | 1270 ............ 301D | 2300 | HI11 | C022-1 | 1270 ............ 302D | 2300 | HI12 | C022-1 | 1270 ............ 303D | 2300 | HI01 | C022-1 | 1270 ............ 304D | 2300 | HI02 | C022-1 | 1270 ............ 305D | 2300 | HI03 | C022-1 | 1270 ............ 306D | 2300 | HI04 | C022-1 | 1270 ............ 307D | 2300 | HI05 | C022-1 | 1270 ............ 307D | 2300 | HI06 | C022-1 | 1270 ............ 308D | 2300 | HI07 | C022-1 | 1270 ............ 309D | 2300 | HI08 | C022-1 | 1270 ............ 309D | 2300 | HI09 | C022-1 | 1270 ............ 310D | 2300 | HI10 | C022-1 | 1270 .............311D | 2300 | HI11 | C022-1 | 1270 .............311D | 2300 | HI12 | C022-1 | 1270 ............ 312

CODE QUALIFIER

Code QualifierCode identifying the type of unit ormeasurement.D | 2300 | CRC01 | - | 1136............. 181D | 2410 | CTP05 | C001-1 | 355 .............. 453

COMMUNICATION NUMBER

Communication NumberComplete communications number includingcountry or area code when applicableH | 1000A | PER04 | - | 364 ................ 74H | 1000A | PER06 | - | 364 ................ 75H | 1000A | PER08 | - | 364 ................ 75D | 2010AA | PER04 | - | 364 ................ 92D | 2010AA | PER06 | - | 364 ................ 93


E.4 MAY 2006

D | 2010AA | PER08 | - | 364 ................ 93COMMUNICATION NUMBER QUALIFIER

Communication NumberQualifierCode identifying the type of communicationnumber.H | 1000A | PER03 | - | 365 ................ 74H | 1000A | PER05 | - | 365 ................ 74H | 1000A | PER07 | - | 365 ................ 75D | 2010AA | PER03 | - | 365 ................ 92D | 2010AA | PER05 | - | 365 ................ 92D | 2010AA | PER07 | - | 365 ................ 93

CONDITION CODE

Condition CodeCode(s) used to identify condition(s) relating tothis bill or relating to the patient.D | 2300 | HI01 | C022-2 | 1271 ............ 294D | 2300 | HI02 | C022-2 | 1271 ............ 295D | 2300 | HI03 | C022-2 | 1271 ............ 296D | 2300 | HI04 | C022-2 | 1271 ............ 297D | 2300 | HI05 | C022-2 | 1271 ............ 297D | 2300 | HI06 | C022-2 | 1271 ............ 298D | 2300 | HI07 | C022-2 | 1271 ............ 299D | 2300 | HI08 | C022-2 | 1271 ............ 300D | 2300 | HI09 | C022-2 | 1271 ............ 300D | 2300 | HI10 | C022-2 | 1271 ............ 301D | 2300 | HI11 | C022-2 | 1271 ............ 302D | 2300 | HI12 | C022-2 | 1271 ............ 303

CONDITION INDICATOR

Condition IndicatorCode indicating a conditionD | 2300 | CRC03 | - | 1321 ............ 182D | 2300 | CRC04 | - | 1321 ............ 182D | 2300 | CRC05 | - | 1321 ............ 183

CONTACT FUNCTION CODE

Contact Function CodeCode identifying the major duty or responsibilityof the person or group named.H | 1000A | PER01 | - | 366 ................ 74D | 2010AA | PER01 | - | 366 ................ 92

CONTRACT AMOUNT

Contract AmountFixed monetary amount pertaining to thecontractD | 2300 | CN102 | - | 782 .............. 158

CONTRACT CODE

Contract CodeCode identifying the specific contract,established by the payer.D | 2300 | CN104 | - | 127 .............. 159

CONTRACT PERCENTAGE

Contract PercentagePercent of charges payable under the contractD | 2300 | CN103 | - | 332 .............. 159

CONTRACT TYPE CODE

Contract Type CodeCode identifying a contract typeD | 2300 | CN101 | - | 1166............. 158

CONTRACT VERSION IDENTIFIER

Contract Version IdentifierIdentification of additional or supplementalcontract provisions, or identification of aparticular version or modification of contract.D | 2300 | CN106 | - | 799 .............. 159

COST REPORT DAY COUNT

Cost Report Day CountThe number of days that may be claimed asMedicare patient days on a cost report.D | 2320 | MIA15 | - | 380 .............. 372

COUNTRY CODE

Country CodeCode indicating the geographic location.D | 2010AA | N404 | - | 26 .................. 89D | 2010AB | N404 | - | 26 .................. 98D | 2010AC | N404 | - | 26 ................ 103D | 2010BA | N404 | - | 26 .................117D | 2010BB | N404 | - | 26 ................ 126D | 2010CA | N404 | - | 26 ................ 139D | 2310E | N404 | - | 26 ................ 346D | 2330A | N404 | - | 26 ................ 382D | 2330B | N404 | - | 26 ................ 388

COUNTRY SUBDIVISION CODE

Country Subdivision CodeCode identifying the country subdivision.D | 2010AA | N407 | - | 1715 .............. 89D | 2010AB | N407 | - | 1715 .............. 98D | 2010AC | N407 | - | 1715 ............ 103D | 2010BA | N407 | - | 1715 .............117D | 2010BB | N407 | - | 1715 ............ 126D | 2010CA | N407 | - | 1715 ............ 139D | 2310E | N407 | - | 1715 ............ 346D | 2330A | N407 | - | 1715 ............ 382D | 2330B | N407 | - | 1715 ............ 388

COVERED DAYS OR VISITS COUNT

Covered Days or Visits CountNumber of days or visits covered by the primarypayer or days/visits that would have beencovered had Medicare been primary.D | 2320 | MIA01 | - | 380 .............. 369

CURRENCY CODE

Currency CodeCode for country in whose currency the chargesare specified.D | 2000A | CUR02 | - | 100 ................ 82

DATE TIME PERIOD FORMAT QUALIFIER

Date Time Period FormatQualifierCode indicating the date format, time format, ordate and time format.D | 2010BA | DMG01 | - | 1250 .............118D | 2010CA | DMG01 | - | 1250 ............ 140D | 2300 | DTP02 | - | 1250 ............ 149D | 2300 | DTP02 | - | 1250 ............ 150D | 2300 | DTP02 | - | 1250 ............ 151D | 2300 | DTP02 | - | 1250 ............ 152D | 2300 | HI01 | C022-3 | 1250 ............ 240D | 2300 | HI01 | C022-3 | 1250 ............ 243D | 2300 | HI02 | C022-3 | 1250 ............ 244D | 2300 | HI03 | C022-3 | 1250 ............ 246D | 2300 | HI04 | C022-3 | 1250 ............ 247D | 2300 | HI05 | C022-3 | 1250 ............ 248D | 2300 | HI06 | C022-3 | 1250 ............ 249


MAY 2006 E.5

D | 2300 | HI07 | C022-3 | 1250 ............ 251D | 2300 | HI08 | C022-3 | 1250 ............ 252D | 2300 | HI09 | C022-3 | 1250 ............ 253D | 2300 | HI10 | C022-3 | 1250 ............ 254D | 2300 | HI11 | C022-3 | 1250 ............ 256D | 2300 | HI12 | C022-3 | 1250 ............ 257D | 2300 | HI01 | C022-3 | 1250 ............ 259D | 2300 | HI02 | C022-3 | 1250 ............ 260D | 2300 | HI03 | C022-3 | 1250 ............ 261D | 2300 | HI04 | C022-3 | 1250 ............ 262D | 2300 | HI05 | C022-3 | 1250 ............ 263D | 2300 | HI06 | C022-3 | 1250 ............ 264D | 2300 | HI07 | C022-3 | 1250 ............ 265D | 2300 | HI08 | C022-3 | 1250 ............ 266D | 2300 | HI09 | C022-3 | 1250 ............ 267D | 2300 | HI10 | C022-3 | 1250 ............ 268D | 2300 | HI11 | C022-3 | 1250 ............ 269D | 2300 | HI12 | C022-3 | 1250 ............ 270D | 2300 | HI01 | C022-3 | 1250 ............ 272D | 2300 | HI02 | C022-3 | 1250 ............ 273D | 2300 | HI03 | C022-3 | 1250 ............ 274D | 2300 | HI04 | C022-3 | 1250 ............ 275D | 2300 | HI05 | C022-3 | 1250 ............ 276D | 2300 | HI06 | C022-3 | 1250 ............ 277D | 2300 | HI07 | C022-3 | 1250 ............ 278D | 2300 | HI08 | C022-3 | 1250 ............ 279D | 2300 | HI09 | C022-3 | 1250 ............ 280D | 2300 | HI10 | C022-3 | 1250 ............ 281D | 2300 | HI11 | C022-3 | 1250 ............ 282D | 2300 | HI12 | C022-3 | 1250 ............ 283D | 2330B | DTP02 | - | 1250 ............ 389D | 2400 | DTP02 | - | 1250 ............ 434D | 2430 | DTP02 | - | 1250 ............ 486

DATE TIME QUALIFIER

Date Time QualifierCode specifying the type of date or time or bothdate and time.D | 2300 | DTP01 | - | 374 .............. 149D | 2300 | DTP01 | - | 374 .............. 150D | 2300 | DTP01 | - | 374 .............. 151D | 2300 | DTP01 | - | 374 .............. 152D | 2330B | DTP01 | - | 374 .............. 389D | 2400 | DTP01 | - | 374 .............. 434D | 2430 | DTP01 | - | 374 .............. 486

DELAY REASON CODE

Delay Reason CodeCode indicating the reason why a request wasdelayed.D | 2300 | CLM20 | - | 1514 ............ 147

DEMONSTRATION PROJECT IDENTIFIER

Demonstration Project IdentifierIdentification number for a Medicaredemonstration project.D | 2300 | REF02 | - | 127 .............. 174

DESCRIPTION

DescriptionA free-form description to clarify the related dataelements and their content.D | 2400 | SV202 | C003-7 | 352 .............. 427

DIAGNOSIS RELATED GROUP (DRG) CODE

Diagnosis Related Group(DRG) CodeDiagnosis related group for this claim.D | 2300 | HI01 | C022-2 | 1271 ............ 219

DISCHARGE TIME

Discharge TimeTime the patient was discharged from theinpatient care.D | 2300 | DTP03 | - | 1251 ............ 149

END STAGE RENAL DISEASE PAYMENT AMOUNT

End Stage Renal DiseasePayment AmountAmount of payment under End Stage RenalDisease benefit.D | 2320 | MOA08 | - | 782 .............. 376

ENTITY IDENTIFIER CODE

Entity Identifier CodeCode identifying an organizational entity, aphysical location, property or an individual.H | 1000A | NM101 | - | 98 .................. 71H | 1000B | NM101 | - | 98 .................. 76D | 2000A | CUR01 | - | 98 .................. 82D | 2010AA | NM101 | - | 98 .................. 85D | 2010AB | NM101 | - | 98 .................. 94D | 2010AC | NM101 | - | 98 .................. 99D | 2010BA | NM101 | - | 98 .................112D | 2010BB | NM101 | - | 98 ................ 122D | 2010CA | NM101 | - | 98 ................ 135D | 2310A | NM101 | - | 98 ................ 319D | 2310B | NM101 | - | 98 ................ 327D | 2310C | NM101 | - | 98 ................ 332D | 2310D | NM101 | - | 98 ................ 337D | 2310E | NM101 | - | 98 ................ 342D | 2310F | NM101 | - | 98 ................ 350D | 2330A | NM101 | - | 98 ................ 378D | 2330B | NM101 | - | 98 ................ 384D | 2330C | NM101 | - | 98 ................ 397D | 2330C | NM101 | - | 98 ................ 397D | 2330D | NM101 | - | 98 ................ 401D | 2330E | NM101 | - | 98 ................ 405D | 2330F | NM101 | - | 98 ................ 409D | 2330G | NM101 | - | 98 ................ 413D | 2330H | NM101 | - | 98 ................ 417D | 2330I | NM101 | - | 98 ................ 421D | 2420A | NM101 | - | 98 ................ 457D | 2420B | NM101 | - | 98 ................ 462D | 2420C | NM101 | - | 98 ................ 467D | 2420D | NM101 | - | 98 ................ 472

ENTITY TYPE QUALIFIER

Entity Type QualifierCode qualifying the type of entity.H | 1000A | NM102 | - | 1065 .............. 72H | 1000B | NM102 | - | 1065 .............. 76D | 2010AA | NM102 | - | 1065 .............. 85D | 2010AB | NM102 | - | 1065 .............. 95D | 2010AC | NM102 | - | 1065 ............ 100D | 2010BA | NM102 | - | 1065 .............113D | 2010BB | NM102 | - | 1065 ............ 123D | 2010CA | NM102 | - | 1065 ............ 135D | 2310A | NM102 | - | 1065 ............ 320D | 2310B | NM102 | - | 1065 ............ 327D | 2310C | NM102 | - | 1065 ............ 332D | 2310D | NM102 | - | 1065 ............ 337D | 2310E | NM102 | - | 1065 ............ 342D | 2310F | NM102 | - | 1065 ............ 350D | 2330A | NM102 | - | 1065 ............ 378D | 2330B | NM102 | - | 1065 ............ 384D | 2330C | NM102 | - | 1065 ............ 397D | 2330C | NM102 | - | 1065 ............ 397D | 2330D | NM102 | - | 1065 ............ 401D | 2330E | NM102 | - | 1065 ............ 405D | 2330F | NM102 | - | 1065 ............ 409D | 2330G | NM102 | - | 1065 ............ 413


E.6 MAY 2006

D | 2330H | NM102 | - | 1065 ............ 417D | 2330I | NM102 | - | 1065 ............ 421D | 2420A | NM102 | - | 1065 ............ 457D | 2420B | NM102 | - | 1065 ............ 462D | 2420C | NM102 | - | 1065 ............ 467D | 2420D | NM102 | - | 1065 ............ 472

EXCEPTION CODE

Exception CodeException code generated by the Third PartyOrganization.D | 2300 | HCP15 | - | 1527 ............ 318D | 2400 | HCP15 | - | 1527 ............ 448

EXTERNAL CAUSE OF INJURY CODE

External Cause of Injury CodeCode identifying the cause of the injury.D | 2300 | HI01 | C022-2 | 1271 ............ 194D | 2300 | HI02 | C022-2 | 1271 ............ 196D | 2300 | HI03 | C022-2 | 1271 ............ 198D | 2300 | HI04 | C022-2 | 1271 ............ 200D | 2300 | HI05 | C022-2 | 1271 ............ 202D | 2300 | HI06 | C022-2 | 1271 ............ 204D | 2300 | HI07 | C022-2 | 1271 ............ 206D | 2300 | HI08 | C022-2 | 1271 ............ 208D | 2300 | HI09 | C022-2 | 1271 ............ 210D | 2300 | HI10 | C022-2 | 1271 ............ 212D | 2300 | HI11 | C022-2 | 1271 ............ 214D | 2300 | HI12 | C022-2 | 1271 ............ 216

FACILITY CODE QUALIFIER

Facility Code QualifierCode identifying the type of facility referenced.D | 2300 | CLM05 | C023-2 | 1332 ............ 145

FACILITY TAX AMOUNT

Facility Tax AmountThe amount of facility tax or surchargeapplicable to the reported service.D | 2400 | AMT02 | - | 782 .............. 440

FACILITY TYPE CODE

Facility Type CodeCode identifying the type of facility whereservices were performed; the first and secondpositions of the Uniform Bill Type code or thePlace of Service code from the Electronic MediaClaims National Standard Format.D | 2300 | CLM05 | C023-1 | 1331 ............ 145

FIXED FORMAT INFORMATION

Fixed Format InformationData in fixed format agreed upon by sender andreceiverD | 2300 | K301 | - | 449 .............. 177

HCPCS PAYABLE AMOUNT

HCPCS Payable AmountAmount due under Medicare HCPCS system.D | 2320 | MOA02 | - | 782 .............. 375

HIERARCHICAL CHILD CODE

Hierarchical Child CodeCode indicating if there are hierarchical childdata segments subordinate to the level beingdescribed.D | 2000A | HL04 | - | 736 ................ 79D | 2000B | HL04 | - | 736 .............. 108D | 2000C | HL04 | - | 736 .............. 132

HIERARCHICAL ID NUMBER

Hierarchical ID NumberA unique number assigned by the sender toidentify a particular data segment in ahierarchical structure.D | 2000A | HL01 | - | 628 ................ 78D | 2000B | HL01 | - | 628 .............. 107D | 2000C | HL01 | - | 628 .............. 131

HIERARCHICAL LEVEL CODE

Hierarchical Level CodeCode defining the characteristic of a level in ahierarchical structure.D | 2000A | HL03 | - | 735 ................ 78D | 2000B | HL03 | - | 735 .............. 108D | 2000C | HL03 | - | 735 .............. 132

HIERARCHICAL PARENT ID NUMBER

Hierarchical Parent ID NumberIdentification number of the next higherhierarchical data segment that the datasegment being described is subordinate to.D | 2000B | HL02 | - | 734 .............. 108D | 2000C | HL02 | - | 734 .............. 132

HIERARCHICAL STRUCTURE CODE

Hierarchical Structure CodeCode indicating the hierarchical applicationstructure of a transaction set that utilizes the HLsegment to define the structure of thetransaction setH | | BHT01 | - | 1005 .............. 68

IDENTIFICATION CODE QUALIFIER

Identification Code QualifierCode designating the system/method of codestructure used for Identification Code (67).H | 1000A | NM108 | - | 66 .................. 72H | 1000B | NM108 | - | 66 .................. 77D | 2010AA | NM108 | - | 66 .................. 86D | 2010AC | NM108 | - | 66 ................ 100D | 2010BA | NM108 | - | 66 .................113D | 2010BB | NM108 | - | 66 ................ 123D | 2300 | PWK05 | - | 66 ................ 157D | 2310A | NM108 | - | 66 ................ 321D | 2310B | NM108 | - | 66 ................ 328D | 2310C | NM108 | - | 66 ................ 333D | 2310D | NM108 | - | 66 ................ 338D | 2310E | NM108 | - | 66 ................ 342D | 2310F | NM108 | - | 66 ................ 351D | 2330A | NM108 | - | 66 ................ 379D | 2330B | NM108 | - | 66 ................ 385D | 2400 | PWK05 | - | 66 ................ 432D | 2420A | NM108 | - | 66 ................ 458D | 2420B | NM108 | - | 66 ................ 463D | 2420C | NM108 | - | 66 ................ 468D | 2420D | NM108 | - | 66 ................ 473

INDIVIDUAL RELATIONSHIP CODE

Individual Relationship CodeCode indicating the relationship between twoindividuals or entities.D | 2000B | SBR02 | - | 1069 .............110D | 2000C | PAT01 | - | 1069 ............ 133D | 2320 | SBR02 | - | 1069 ............ 355

INSURED GROUP OR POLICY NUMBER


MAY 2006 E.7

Insured Group or PolicyNumberThe identification number, control number, orcode assigned by the carrier or administrator toidentify the group under which the individual iscovered.D | 2320 | SBR03 | - | 127 .............. 356

INVESTIGATIONAL DEVICE EXEMPTION IDENTIFIER

Investigational DeviceExemption IdentifierNumber or reference identifying exemptionassigned to an ivestigational device referencedin the claim.D | 2300 | REF02 | - | 127 .............. 169

LABORATORY OR FACILITY ADDRESS LINE

Laboratory or Facility AddressLineAddress line of the laboratory or facilityperforming tests billed on the claim where thehealth care service was performed/rendered.D | 2310E | N301 | - | 166 .............. 344D | 2310E | N302 | - | 166 .............. 344

LABORATORY OR FACILITY CITY NAME

Laboratory or Facility CityNameCity of the laboratory or facility performing testsbilled on the claim where the health careservice was performed/rendered.D | 2310E | N401 | - | 19 ................ 345

LABORATORY OR FACILITY NAME

Laboratory or Facility NameName of laboratory or other facility performingLaboratory testing on the claim where thehealth care service was performed/rendered.D | 2310E | NM103 | - | 1035 ............ 342

LABORATORY OR FACILITY POSTAL ZONE OR ZIP CODE

Laboratory or Facility PostalZone or ZIP CodePostal ZIP or zonal code of the laboratory orfacility performing tests billed on the claimwhere the health care service wasperformed/rendered.D | 2310E | N403 | - | 116............... 346

LABORATORY OR FACILITY PRIMARY IDENTIFIER

Laboratory or Facility PrimaryIdentifierIdentification number of laboratory or otherfacility performing laboratory testing on theclaim where the health care service wasperformed/rendered.D | 2310E | NM109 | - | 67 ................ 342

LABORATORY OR FACILITY SECONDARY IDENTIFIER

Laboratory or FacilitySecondary IdentifierAdditional identifier for the laboratory or facilityperforming tests billed on the claim where thehealth care service was performed/rendered.D | 2310E | REF02 | - | 127 .............. 348

LABORATORY OR FACILITY STATE OR PROVINCE CODE

Laboratory or Facility State orProvince CodeState or province of the laboratory or facilityperforming tests billed on the claim where thehealth care service was performed/rendered.D | 2310E | N402 | - | 156 .............. 346

LIFETIME PSYCHIATRIC DAYS COUNT

Lifetime Psychiatric Days CountNumber of lifetime psychiatric days used for thisclaim.D | 2320 | MIA03 | - | 380 .............. 370

LINE ITEM CHARGE AMOUNT

Line Item Charge AmountCharges related to this service.D | 2400 | SV203 | - | 782 .............. 427

LINE ITEM CONTROL NUMBER

Line Item Control NumberIdentifier assigned by the submitter/provider tothis line item.D | 2400 | REF02 | - | 127 .............. 436

LINE ITEM DENIED CHARGE OR NON-COVERED CHARGE AMOUNT

Line Item Denied Charge orNon-Covered Charge AmountLine item charges denied or not covered.D | 2400 | SV207 | - | 782 .............. 428

LINE NOTE TEXT

Line Note TextNarrative text providing additional informationrelated to the service line.D | 2400 | NTE02 | - | 352 .............. 441

MEDICAL RECORD NUMBER

Medical Record NumberA unique number assigned to patient by theprovider to assist in retrieval of medical records.D | 2300 | REF02 | - | 127 .............. 173

MONETARY AMOUNT

Monetary AmountMonetary amount.D | 2400 | HCP02 | - | 782 .............. 443D | 2400 | HCP03 | - | 782 .............. 443D | 2400 | HCP07 | - | 782 .............. 444

NATIONAL DRUG CODE

National Drug CodeThe national drug identification numberassigned by the Federal Drug Administration(FDA).D | 2410 | LIN03 | - | 234 .............. 451

NATIONAL DRUG UNIT COUNT

National Drug Unit CountThe dispensing quantity, based upon the unit ofmeasure as defined by the National Drug Code.D | 2410 | CTP04 | - | 380 .............. 452

NON-COVERED CHARGE AMOUNT


E.8 MAY 2006

Non-Covered Charge AmountCharges pertaining to the related revenuecenter code that the primary payer will not cover.D | 2320 | AMT02 | - | 782 .............. 366

NON-PAYABLE PROFESSIONAL COMPONENT BILLED AMOUNT

Non-Payable ProfessionalComponent Billed AmountAmount of non-payable charges included in thebill related to professional services.D | 2320 | MIA19 | - | 782 .............. 372D | 2320 | MOA09 | - | 782 .............. 376

NOTE REFERENCE CODE

Note Reference CodeCode identifying the functional area or purposefor which the note applies.D | 2300 | NTE01 | - | 363 .............. 178D | 2300 | NTE01 | - | 363 .............. 180D | 2400 | NTE01 | - | 363 .............. 441

OCCURRENCE CODE

Occurrence CodeA code defining a significant event relating tothis bill that may affect payer processing.D | 2300 | HI01 | C022-2 | 1271 ............ 271D | 2300 | HI02 | C022-2 | 1271 ............ 272D | 2300 | HI03 | C022-2 | 1271 ............ 273D | 2300 | HI04 | C022-2 | 1271 ............ 274D | 2300 | HI05 | C022-2 | 1271 ............ 275D | 2300 | HI06 | C022-2 | 1271 ............ 276D | 2300 | HI07 | C022-2 | 1271 ............ 277D | 2300 | HI08 | C022-2 | 1271 ............ 278D | 2300 | HI09 | C022-2 | 1271 ............ 279D | 2300 | HI10 | C022-2 | 1271 ............ 280D | 2300 | HI11 | C022-2 | 1271 ............ 281D | 2300 | HI12 | C022-2 | 1271 ............ 282

OCCURRENCE CODE DATE

Occurrence Code DateDate associated with the Occurrence Codereported in this composite element.D | 2300 | HI01 | C022-4 | 1251 ............ 272D | 2300 | HI02 | C022-4 | 1251 ............ 273D | 2300 | HI03 | C022-4 | 1251 ............ 274D | 2300 | HI04 | C022-4 | 1251 ............ 275D | 2300 | HI05 | C022-4 | 1251 ............ 276D | 2300 | HI06 | C022-4 | 1251 ............ 277D | 2300 | HI07 | C022-4 | 1251 ............ 278D | 2300 | HI08 | C022-4 | 1251 ............ 279D | 2300 | HI09 | C022-4 | 1251 ............ 280D | 2300 | HI10 | C022-4 | 1251 ............ 281D | 2300 | HI11 | C022-4 | 1251 ............ 282D | 2300 | HI12 | C022-4 | 1251 ............ 283

OCCURRENCE SPAN CODE

Occurrence Span CodeA code that identifies an event that relates topayment of the claim. This event occurs over aspan of days.D | 2300 | HI01 | C022-2 | 1271 ............ 258D | 2300 | HI02 | C022-2 | 1271 ............ 259D | 2300 | HI03 | C022-2 | 1271 ............ 260D | 2300 | HI04 | C022-2 | 1271 ............ 261D | 2300 | HI05 | C022-2 | 1271 ............ 262D | 2300 | HI06 | C022-2 | 1271 ............ 263D | 2300 | HI07 | C022-2 | 1271 ............ 264D | 2300 | HI08 | C022-2 | 1271 ............ 265D | 2300 | HI09 | C022-2 | 1271 ............ 266D | 2300 | HI10 | C022-2 | 1271 ............ 267

D | 2300 | HI11 | C022-2 | 1271 ............ 268D | 2300 | HI12 | C022-2 | 1271 ............ 269

OCCURRENCE SPAN CODE DATE

Occurrence Span Code DateDate associated with the Occurrence SpanCode reported in this composite element.D | 2300 | HI01 | C022-4 | 1251 ............ 259D | 2300 | HI02 | C022-4 | 1251 ............ 260D | 2300 | HI03 | C022-4 | 1251 ............ 261D | 2300 | HI04 | C022-4 | 1251 ............ 262D | 2300 | HI05 | C022-4 | 1251 ............ 263D | 2300 | HI06 | C022-4 | 1251 ............ 264D | 2300 | HI07 | C022-4 | 1251 ............ 265D | 2300 | HI08 | C022-4 | 1251 ............ 266D | 2300 | HI09 | C022-4 | 1251 ............ 267D | 2300 | HI10 | C022-4 | 1251 ............ 268D | 2300 | HI11 | C022-4 | 1251 ............ 269D | 2300 | HI12 | C022-4 | 1251 ............ 270

OLD CAPITAL AMOUNT

Old Capital AmountThe amount for old capital for this claim.D | 2320 | MIA12 | - | 782 .............. 371

OPERATING PHYSICIAN FIRST NAME

Operating Physician First NameFirst name of the physician performing theprinciple procedure.D | 2310B | NM104 | - | 1036 ............ 327D | 2420A | NM104 | - | 1036 ............ 457

OPERATING PHYSICIAN LAST NAME

Operating Physician Last NameLast name of the physician performing theprinciple procedure.D | 2310B | NM103 | - | 1035 ............ 327D | 2420A | NM103 | - | 1035 ............ 457

OPERATING PHYSICIAN MIDDLE NAME OR INITIAL

Operating Physician MiddleName or InitialMiddle name or initial of the physicianperforming the principal procedure.D | 2310B | NM105 | - | 1037 ............ 327D | 2420A | NM105 | - | 1037 ............ 457

OPERATING PHYSICIAN NAME SUFFIX

Operating Physician NameSuffixSuffix to the name of the physician performingthe principal procedure.D | 2310B | NM107 | - | 1039 ............ 327D | 2420A | NM107 | - | 1039 ............ 457

OPERATING PHYSICIAN PRIMARY IDENTIFIER

Operating Physician PrimaryIdentifierPrimary identifier of the physician performingthe principle procedure.D | 2310B | NM109 | - | 67 ................ 328D | 2420A | NM109 | - | 67 ................ 458

OPERATING PHYSICIAN SECONDARY IDENTIFIER


MAY 2006 E.9

Operating PhysicianSecondary IdentifierAdditional identifier for the physician performingthe principal procedure.D | 2310B | REF02 | - | 127 .............. 330D | 2420A | REF02 | - | 127 .............. 460

ORIGINATOR APPLICATION TRANSACTION IDENTIFIER

Originator ApplicationTransaction IdentifierAn identification number that identifies atransaction within the originator’s applicationssystem.H | | BHT03 | - | 127 ................ 69

OTHER DIAGNOSIS

Other DiagnosisOther diagnosis for this claim.D | 2300 | HI01 | C022-2 | 1271 ............ 221D | 2300 | HI02 | C022-2 | 1271 ............ 222D | 2300 | HI03 | C022-2 | 1271 ............ 224D | 2300 | HI04 | C022-2 | 1271 ............ 225D | 2300 | HI05 | C022-2 | 1271 ............ 227D | 2300 | HI06 | C022-2 | 1271 ............ 228D | 2300 | HI07 | C022-2 | 1271 ............ 230D | 2300 | HI08 | C022-2 | 1271 ............ 231D | 2300 | HI09 | C022-2 | 1271 ............ 233D | 2300 | HI10 | C022-2 | 1271 ............ 234D | 2300 | HI11 | C022-2 | 1271 ............ 236D | 2300 | HI12 | C022-2 | 1271 ............ 237

OTHER INSURED ADDITIONAL IDENTIFIER

Other Insured AdditionalIdentifierNumber providing additional identification of theother insured.D | 2330A | REF02 | - | 127 .............. 383

OTHER INSURED ADDRESS LINE

Other Insured Address LineAddress line of the additional insuredindividual’s mailing address.D | 2330A | N301 | - | 166 .............. 380D | 2330A | N302 | - | 166 .............. 380

OTHER INSURED CITY NAME

Other Insured City NameThe city name of the additional insuredindividual.D | 2330A | N401 | - | 19 ................ 381

OTHER INSURED FIRST NAME

Other Insured First NameThe first name of the additional insuredindividual.D | 2330A | NM104 | - | 1036 ............ 378

OTHER INSURED GROUP NAME

Other Insured Group NameName of the group or plan through which theinsurance is provided to the other insured.D | 2320 | SBR04 | - | 93 ................ 356

OTHER INSURED IDENTIFIER

Other Insured IdentifierAn identification number, assigned by the thirdparty payer, to identify the additional insuredindividual.D | 2330A | NM109 | - | 67 ................ 379

OTHER INSURED LAST NAME

Other Insured Last NameThe last name of the additional insuredindividual.D | 2330A | NM103 | - | 1035 ............ 378

OTHER INSURED MIDDLE NAME

Other Insured Middle NameThe middle name of the additional insuredindividual.D | 2330A | NM105 | - | 1037 ............ 378

OTHER INSURED NAME SUFFIX

Other Insured Name SuffixThe suffix to the name of the additional insuredindividual.D | 2330A | NM107 | - | 1039 ............ 378

OTHER INSURED POSTAL ZONE OR ZIP CODE

Other Insured Postal Zone orZIP CodeThe Postal ZIP code of the additional insuredindividual’s mailing address.D | 2330A | N403 | - | 116............... 382

OTHER INSURED STATE CODE

Other Insured State CodeThe state code of the additional insuredindividual’s mailing address.D | 2330A | N402 | - | 156 .............. 382

OTHER OPERATING PHYSICIAN FIRST NAME

Other Operating PhysicianFirst NameFirst Name of the individual performing asecondary surgical procedure or assisting theOperating Physician.D | 2310C | NM104 | - | 1036 ............ 332D | 2420B | NM104 | - | 1036 ............ 462

OTHER OPERATING PHYSICIAN IDENTIFIER

Other Operating PhysicianIdentifierNational identifier for the individual performing asecondary surgical procedure or assisting theOperating Physician.D | 2310C | NM109 | - | 67 ................ 333D | 2420B | NM109 | - | 67 ................ 463

OTHER OPERATING PHYSICIAN LAST NAME

Other Operating Physician LastNameLast Name of the individual performing asecondary surgical procedure or assisting theOperating Physician.D | 2310C | NM103 | - | 1035 ............ 332D | 2420B | NM103 | - | 1035 ............ 462

OTHER OPERATING PHYSICIAN MIDDLE NAME OR INITIAL


E.10 MAY 2006

Other Operating PhysicianMiddle Name or InitialMiddle name or initial of the individualperforming a secondary surgical procedure orassisting the Operating Physician.D | 2310C | NM105 | - | 1037 ............ 332D | 2420B | NM105 | - | 1037 ............ 462

OTHER OPERATING PHYSICIAN NAME SUFFIX

Other Operating PhysicianName SuffixSuffix to the name of the individual performing asecondary surgical procedure or assisting theOperating Physician.D | 2310C | NM107 | - | 1039 ............ 332D | 2420B | NM107 | - | 1039 ............ 462

OTHER PAYER ADDRESS LINE

Other Payer Address LineAddress line of the other payer’s mailingaddress.D | 2330B | N301 | - | 166 .............. 386D | 2330B | N302 | - | 166 .............. 386

OTHER PAYER ATTENDING PROVIDER SECONDARY IDENTIFIER

Other Payer Attending ProviderSecondary IdentifierThe non-destination (COB) payer’s attendingprovider identification.D | 2330C | REF02 | - | 127 .............. 399

OTHER PAYER BILLING PROVIDER IDENTIFIER

Other Payer Billing ProviderIdentifierThe non-destination (COB) payer’s identifier forthe provider or organization in whose name thebill is submitted and to whom payment shouldbe made.D | 2330I | REF02 | - | 127 .............. 422

OTHER PAYER CITY NAME

Other Payer City NameThe city name of the other payer’s mailingaddress.D | 2330B | N401 | - | 19 ................ 387

OTHER PAYER CLAIM ADJUSTMENT INDICATOR

Other Payer Claim AdjustmentIndicatorIndicates the other payer has made a previousclaim adjustment to this claim.D | 2330B | REF02 | - | 127 .............. 394

OTHER PAYER LAST OR ORGANIZATION NAME

Other Payer Last orOrganization NameThe name of the other payer organization.D | 2330B | NM103 | - | 1035 ............ 385

OTHER PAYER OPERATING PROVIDER SECONDARY IDENTIFIER

Other Payer Operating ProviderSecondary IdentifierThe non-destination (COB) payer’s operatingprovider identification.D | 2330D | REF02 | - | 127 .............. 403

OTHER PAYER OTHER OPERATING PHYSICIAN SECONDARY IDENTIFIER

Other Payer Other OperatingPhysician Secondary IdentifierThe non-destination (COB) payer’s identifier forthe individual performing a secondary surgicalprocedure or assisting the Operating Physician.D | 2330E | REF02 | - | 127 .............. 407

OTHER PAYER POSTAL ZONE OR ZIP CODE

Other Payer Postal Zone or ZIPCodeThe ZIP code of the other payer’s mailingaddress.D | 2330B | N403 | - | 116............... 388

OTHER PAYER PRIMARY IDENTIFIER

Other Payer Primary IdentifierAn identification number for the other payer.D | 2330B | NM109 | - | 67 ................ 385D | 2420A | REF04 | C040-2 | 127 .............. 460D | 2420B | REF04 | C040-2 | 127 .............. 465D | 2420C | REF04 | C040-2 | 127 .............. 470D | 2420D | REF04 | C040-2 | 127 .............. 475D | 2430 | SVD01 | - | 67 ................ 476

OTHER PAYER PRIOR AUTHORIZATION NUMBER

Other Payer Prior AuthorizationNumberThe non-destination (COB) payer’s priorauthorization number.D | 2330B | REF02 | - | 127 .............. 392

OTHER PAYER PRIOR AUTHORIZATION OR REFERRAL NUMBER

Other Payer Prior Authorizationor Referral NumberThe non-destination (COB) payer’s priorauthorization or referral number.D | 2330B | REF02 | - | 127 .............. 393

OTHER PAYER REFERRING PROVIDER IDENTIFIER

Other Payer Referring ProviderIdentifierThe non-destination (COB) payer’s referringprovider identifier.D | 2330H | REF02 | - | 127 .............. 419

OTHER PAYER RENDERING PROVIDER SECONDARY IDENTIFIER

Other Payer RenderingProvider Secondary IdentifierThe non-destination (COB) payer’s renderingprovider identifier.D | 2330G | REF02 | - | 127 .............. 415

OTHER PAYER SECONDARY IDENTIFIER

Other Payer SecondaryIdentifierAdditional identifier for the other payerorganizationD | 2330B | REF02 | - | 127 .............. 391

OTHER PAYER SERVICE FACILITY LOCATION IDENTIFIER

Other Payer Service FacilityLocation IdentifierThe non-destination (COB) payer’s servicefacility location identifier.D | 2330F | REF02 | - | 127 .............. 410

OTHER PAYER STATE CODE


MAY 2006 E.11

Other Payer State CodeThe state or province code of the other payer’smailing address.D | 2330B | N402 | - | 156 .............. 387

OTHER PAYER’S CLAIM CONTROL NUMBER

Other Payer’s Claim ControlNumberA number assigned by the other payer toidentify a claim. The number is usually referredto as an Internal Control Number (ICN), ClaimControl Number (CCN) or a Document ControlNumber (DCN).D | 2330B | REF02 | - | 127 .............. 395

OTHER PROVIDER SECONDARY IDENTIFIER

Other Provider SecondaryIdentifierAdditional identification number of the otherprovider as defined by the payer organization.D | 2310C | REF02 | - | 127 .............. 335D | 2420B | REF02 | - | 127 .............. 465

PPS-CAPITAL DSH DRG AMOUNT

PPS-Capital DSH DRG AmountPPS-capital disproportionate share amount forthis claim as output by PPS-PRICER.D | 2320 | MIA11 | - | 782 .............. 371

PPS-CAPITAL EXCEPTION AMOUNT

PPS-Capital Exception AmountA per discharge payment exception paid to thehospital. It is a flat-rate add-on to the PPSpayment.D | 2320 | MIA24 | - | 782 .............. 373

PPS-CAPITAL FSP DRG AMOUNT

PPS-Capital FSP DRG AmountPPS-capital federal portion for this claim asoutput by PPS-PRICER.D | 2320 | MIA09 | - | 782 .............. 371

PPS-CAPITAL HSP DRG AMOUNT

PPS-Capital HSP DRG AmountHospital-Specific portion for PPS-capital for thisclaim as output by PPS-PRICER.D | 2320 | MIA10 | - | 782 .............. 371

PPS-CAPITAL IME AMOUNT

PPS-Capital IME amountPPS-capital indirect medical expenses for thisclaim as output by PPS-PRICER.D | 2320 | MIA13 | - | 782 .............. 371

PPS-OPERATING FEDERAL SPECIFIC DRG AMOUNT

PPS-Operating Federal SpecificDRG AmountSum of federal operating portion of the DRGamount this claim as output by PPS-PRICER.D | 2320 | MIA16 | - | 782 .............. 372

PPS-OPERATING HOSPITAL SPECIFIC DRG AMOUNT

PPS-Operating HospitalSpecific DRG AmountSum of hospital specific operating portion ofDRG amount for this claim as output byPPS-PRICER.D | 2320 | MIA14 | - | 782 .............. 371

PAID SERVICE UNIT COUNT

Paid Service Unit CountUnits of service paid by the payer forcoordination of benefits.D | 2430 | SVD05 | - | 380 .............. 479

PATIENT ADDRESS LINE

Patient Address LineAddress line of the street mailing address of thepatient.D | 2010CA | N301 | - | 166 .............. 137D | 2010CA | N302 | - | 166 .............. 137

PATIENT BIRTH DATE

Patient Birth DateDate of birth of the patient.D | 2010CA | DMG02 | - | 1251 ............ 140

PATIENT CITY NAME

Patient City NameThe city name of the patient.D | 2010CA | N401 | - | 19 ................ 138

PATIENT CONTROL NUMBER

Patient Control NumberPatient’s unique alpha-numeric identificationnumber for this claim assigned by the providerto facilitate retrieval of individual case recordsand posting of payment.D | 2300 | CLM01 | - | 1028 ............ 144

PATIENT FIRST NAME

Patient First NameThe first name of the individual to whom theservices were provided.D | 2010CA | NM104 | - | 1036 ............ 136

PATIENT GENDER CODE

Patient Gender CodeA code indicating the sex of the patient.D | 2010CA | DMG03 | - | 1068 ............ 141

PATIENT LAST NAME

Patient Last NameThe last name of the individual to whom theservices were provided.D | 2010CA | NM103 | - | 1035 ............ 136

PATIENT MIDDLE NAME OR INITIAL

Patient Middle Name or InitialThe middle name or initial of the individual towhom the services were provided.D | 2010CA | NM105 | - | 1037 ............ 136

PATIENT NAME SUFFIX

Patient Name SuffixSuffix to the name of the individual to whom theservices were provided.D | 2010CA | NM107 | - | 1039 ............ 136

PATIENT POSTAL ZONE OR ZIP CODE


E.12 MAY 2006

Patient Postal Zone or ZIP CodeThe ZIP Code of the patient.D | 2010CA | N403 | - | 116............... 139

PATIENT REASON FOR VISIT

Patient Reason For VisitThe diagnosis code describing the patient’sreason for visit at the time of outpatientregistration.D | 2300 | HI01 | C022-2 | 1271 ............ 190D | 2300 | HI02 | C022-2 | 1271 ............ 191D | 2300 | HI03 | C022-2 | 1271 ............ 192

PATIENT RESPONSIBILITY AMOUNT

Patient Responsibility AmountThe amount determined to be the patient’sresponsibility for payment.D | 2300 | AMT02 | - | 782 .............. 160

PATIENT STATE CODE

Patient State CodeThe State Postal Code of the patient.D | 2010CA | N402 | - | 156 .............. 138

PATIENT STATUS CODE

Patient Status CodeA code indicating the patient’s status at the dateof admission, outpatient service, or start of care.D | 2300 | CL103 | - | 1352 ............ 153

PAY-TO ADDRESS LINE

Pay-To Address LineAddress line of the provider to receive payment.D | 2010AB | N301 | - | 166 ................ 96D | 2010AB | N302 | - | 166 ................ 96

PAY-TO PLAN ADDRESS LINE

Pay-To Plan Address LineStreet address of the Pay-To Plan.D | 2010AC | N301 | - | 166 .............. 101D | 2010AC | N302 | - | 166 .............. 101

PAY-TO PLAN CITY NAME

Pay-To Plan City NameCity name of the Pay-To Plan.D | 2010AC | N401 | - | 19 ................ 102

PAY-TO PLAN ORGANIZATIONAL NAME

Pay-To Plan OrganizationalNameOrganization name of the health plan that isseeking reimbursement (Pay-To Plan).D | 2010AC | NM103 | - | 1035 ............ 100

PAY-TO PLAN POSTAL ZONE OR ZIP CODE

Pay-To Plan Postal Zone or ZIPCodePostal zone or ZIP code of the Pay-To Plan.D | 2010AC | N403 | - | 116............... 103

PAY-TO PLAN PRIMARY IDENTIFIER

Pay-To Plan Primary IdentifierIdentification number for the Pay-To Plan.D | 2010AC | NM109 | - | 67 ................ 100

PAY-TO PLAN STATE OR PROVINCE CODE

Pay-To Plan State or ProvinceCodeState or province code of the Pay-to Plan.D | 2010AC | N402 | - | 156 .............. 102

PAY-TO PLAN TAX IDENTIFICATION NUMBER

Pay-To Plan Tax IdentificationNumberTax identification number of the plan to whompayment should be made.D | 2010AC | REF02 | - | 127 .............. 106

PAY-TO ADDRESS CITY NAME

Pay-to Address City NameCity name of the entity to receive payment.D | 2010AB | N401 | - | 19 .................. 97

PAY-TO ADDRESS POSTAL ZONE OR ZIP CODE

Pay-to Address Postal Zone orZIP CodePostal code of the entity to receive payment (forexample, ZIP code).D | 2010AB | N403 | - | 116................. 98

PAY-TO ADDRESS STATE CODE

Pay-to Address State CodeState or sub-country code of the entity toreceive payment.D | 2010AB | N402 | - | 156 ................ 98

PAY-TO PLAN SECONDARY IDENTIFIER

Pay-to Plan SecondaryIdentifierAdditional identifier for the Pay-To Plan.D | 2010AC | REF02 | - | 127 .............. 104

PAYER ADDITIONAL IDENTIFIER

Payer Additional IdentifierAdditional identifier for the payer.D | 2010BB | REF02 | - | 127 .............. 128

PAYER ADDRESS LINE

Payer Address LineAddress line of the Payer’s claim mailingaddress for this particular payer organizationidentification and claim office.D | 2010BB | N301 | - | 166 .............. 124D | 2010BB | N302 | - | 166 .............. 124

PAYER CITY NAME

Payer City NameThe City Name of the Payer’s claim mailingaddress for this particular payer ID and claimoffice.D | 2010BB | N401 | - | 19 ................ 125

PAYER CLAIM CONTROL NUMBER

Payer Claim Control NumberA number assigned by the payer to identify aclaim. The number is usually referred to as anInternal Control Number (ICN), Claim ControlNumber (CCN) or a Document Control Number(DCN).D | 2300 | REF02 | - | 127 .............. 166

PAYER IDENTIFIER


MAY 2006 E.13

Payer IdentifierNumber identifying the payer organization.D | 2010BB | NM109 | - | 67 ................ 123

PAYER NAME

Payer NameName identifying the payer organization.D | 2010BB | NM103 | - | 1035 ............ 123

PAYER PAID AMOUNT

Payer Paid AmountThe amount paid by the payer on this claim.D | 2320 | AMT02 | - | 782 .............. 364

PAYER POSTAL ZONE OR ZIP CODE

Payer Postal Zone or ZIP CodeThe ZIP Code of the Payer’s claim mailingaddress for this particular payer organizationidentification and claim office.D | 2010BB | N403 | - | 116............... 126

PAYER RESPONSIBILITY SEQUENCE NUMBER CODE

Payer Responsibility SequenceNumber CodeCode identifying the insurance carrier’s level ofresponsibility for a payment of a claimD | 2000B | SBR01 | - | 1138............. 109D | 2320 | SBR01 | - | 1138............. 355

PAYER STATE CODE

Payer State CodeState Postal Code of the Payer’s claim mailingaddress for this particular payor organizationidentification and claim office.D | 2010BB | N402 | - | 156 .............. 125

PEER REVIEW AUTHORIZATION NUMBER

Peer Review AuthorizationNumberAuthorization number provided by a revieworganization after review completed.D | 2300 | REF02 | - | 127 .............. 175

POLICY COMPLIANCE CODE

Policy Compliance CodeThe code that specifies policy compliance.D | 2300 | HCP14 | - | 1526 ............ 317D | 2400 | HCP14 | - | 1526 ............ 448

PRESCRIPTION NUMBER

Prescription NumberThe unique identification number assigned bythe pharmacy or supplier to the prescription.D | 2410 | REF02 | - | 127 .............. 455

PRESENT ON ADMISSION INDICATOR

Present on Admission IndicatorCode which provides an indication as towhether the diagnosis was present at the timeof adimission.D | 2300 | HI01 | C022-9 | 1073 ............ 185D | 2300 | HI01 | C022-9 | 1073 ............ 195D | 2300 | HI02 | C022-9 | 1073 ............ 197D | 2300 | HI03 | C022-9 | 1073 ............ 199D | 2300 | HI04 | C022-9 | 1073 ............ 201D | 2300 | HI05 | C022-9 | 1073 ............ 203D | 2300 | HI06 | C022-9 | 1073 ............ 205

D | 2300 | HI07 | C022-9 | 1073 ............ 207D | 2300 | HI08 | C022-9 | 1073 ............ 209D | 2300 | HI09 | C022-9 | 1073 .............211D | 2300 | HI10 | C022-9 | 1073 ............ 213D | 2300 | HI11 | C022-9 | 1073 ............ 215D | 2300 | HI12 | C022-9 | 1073 ............ 217D | 2300 | HI01 | C022-9 | 1073 ............ 221D | 2300 | HI02 | C022-9 | 1073 ............ 223D | 2300 | HI03 | C022-9 | 1073 ............ 224D | 2300 | HI04 | C022-9 | 1073 ............ 226D | 2300 | HI05 | C022-9 | 1073 ............ 227D | 2300 | HI06 | C022-9 | 1073 ............ 229D | 2300 | HI07 | C022-9 | 1073 ............ 230D | 2300 | HI08 | C022-9 | 1073 ............ 232D | 2300 | HI09 | C022-9 | 1073 ............ 233D | 2300 | HI10 | C022-9 | 1073 ............ 235D | 2300 | HI11 | C022-9 | 1073 ............ 236D | 2300 | HI12 | C022-9 | 1073 ............ 238

PRICING METHODOLOGY

Pricing MethodologyPricing methodology at which the claim or lineitem has been priced or repriced.D | 2300 | HCP01 | - | 1473 ............ 314D | 2400 | HCP01 | - | 1473 ............ 443

PRINCIPAL DIAGNOSIS CODE

Principal Diagnosis CodeThe diagnosis code describing the conditionestablished, after study, to be chieflyresponsible for occasioning the admission ofthe patient for care.D | 2300 | HI01 | C022-2 | 1271 ............ 185

PRINCIPAL PROCEDURE CODE

Principal Procedure CodeCode identifying the principal procedure,product or service.D | 2300 | HI01 | C022-2 | 1271 ............ 240

PRINCIPAL PROCEDURE DATE

Principal Procedure DateDate on which the Principal Procedure wasperformed.D | 2300 | HI01 | C022-4 | 1251 ............ 240

PRIOR AUTHORIZATION NUMBER

Prior Authorization NumberA number, code or other value that indicates theservices provided on this claim have beenauthorized by the payee or other serviceorganization.D | 2300 | REF02 | - | 127 .............. 165

PROCEDURE CODE

Procedure CodeCode identifying the procedure, product orservice.D | 2300 | HI01 | C022-2 | 1271 ............ 243D | 2300 | HI02 | C022-2 | 1271 ............ 244D | 2300 | HI03 | C022-2 | 1271 ............ 245D | 2300 | HI04 | C022-2 | 1271 ............ 247D | 2300 | HI05 | C022-2 | 1271 ............ 248D | 2300 | HI06 | C022-2 | 1271 ............ 249D | 2300 | HI07 | C022-2 | 1271 ............ 250D | 2300 | HI08 | C022-2 | 1271 ............ 252D | 2300 | HI09 | C022-2 | 1271 ............ 253D | 2300 | HI10 | C022-2 | 1271 ............ 254D | 2300 | HI11 | C022-2 | 1271 ............ 255D | 2300 | HI12 | C022-2 | 1271 ............ 257


E.14 MAY 2006

D | 2400 | SV202 | C003-2 | 234 .............. 426D | 2430 | SVD03 | C003-2 | 234 .............. 478

PROCEDURE CODE DESCRIPTION

Procedure Code DescriptionDescription clarifying the Product/ServiceProcedure Code and related data elements.D | 2430 | SVD03 | C003-7 | 352 .............. 479

PROCEDURE DATE

Procedure DateDate when the health care procedure wasperformed.D | 2300 | HI01 | C022-4 | 1251 ............ 243D | 2300 | HI02 | C022-4 | 1251 ............ 245D | 2300 | HI03 | C022-4 | 1251 ............ 246D | 2300 | HI04 | C022-4 | 1251 ............ 247D | 2300 | HI05 | C022-4 | 1251 ............ 248D | 2300 | HI06 | C022-4 | 1251 ............ 250D | 2300 | HI07 | C022-4 | 1251 ............ 251D | 2300 | HI08 | C022-4 | 1251 ............ 252D | 2300 | HI09 | C022-4 | 1251 ............ 253D | 2300 | HI10 | C022-4 | 1251 ............ 255D | 2300 | HI11 | C022-4 | 1251 ............ 256D | 2300 | HI12 | C022-4 | 1251 ............ 257

PROCEDURE MODIFIER

Procedure ModifierThis identifies special circumstances related tothe performance of the service.D | 2400 | SV202 | C003-3 | 1339 ............ 426D | 2400 | SV202 | C003-4 | 1339 ............ 426D | 2400 | SV202 | C003-5 | 1339 ............ 427D | 2400 | SV202 | C003-6 | 1339 ............ 427D | 2430 | SVD03 | C003-3 | 1339 ............ 478D | 2430 | SVD03 | C003-4 | 1339 ............ 478D | 2430 | SVD03 | C003-5 | 1339 ............ 478D | 2430 | SVD03 | C003-6 | 1339 ............ 479

PRODUCT OR SERVICE ID

Product or Service IDIdentifying number for a product or service.D | 2400 | HCP08 | - | 234 .............. 445

PRODUCT OR SERVICE ID QUALIFIER

Product or Service ID QualifierCode identifying the type/source of thedescriptive number used in Product/Service ID(234).D | 2400 | SV202 | C003-1 | 235 .............. 425D | 2400 | HCP09 | - | 235 .............. 445D | 2410 | LIN02 | - | 235 .............. 451D | 2430 | SVD03 | C003-1 | 235 .............. 477

PROPERTY CASUALTY CLAIM NUMBER

Property Casualty ClaimNumberIdentification number for property casualty claimassociated with the services identified on the bill.D | 2010BA | REF02 | - | 127 .............. 121D | 2010CA | REF02 | - | 127 .............. 142

PROVIDER CODE

Provider CodeCode identifying the type of provider.D | 2000A | PRV01 | - | 1221 .............. 80D | 2310A | PRV01 | - | 1221 ............ 322

PROVIDER TAXONOMY CODE

Provider Taxonomy CodeCode designating the provider type,classification, and specialization.D | 2000A | PRV03 | - | 127 ................ 80D | 2310A | PRV03 | - | 127 .............. 322

QUANTITY

QuantityNumeric value of quantity.D | 2400 | HCP12 | - | 380 .............. 447

RATE

RateRate expressed in the standard monetarydenomination for the currency specified.D | 2400 | HCP05 | - | 118............... 444

RECEIVER NAME

Receiver NameName of organization receiving the transaction.H | 1000B | NM103 | - | 1035 .............. 77

RECEIVER PRIMARY IDENTIFIER

Receiver Primary IdentifierPrimary identification number for the receiver ofthe transaction.H | 1000B | NM109 | - | 67 .................. 77

REFERENCE IDENTIFICATION

Reference IdentificationThe identification value assigned by the senderfor this particular transaction.D | 2400 | HCP04 | - | 127 .............. 444D | 2400 | HCP06 | - | 127 .............. 444

REFERENCE IDENTIFICATION QUALIFIER

Reference IdentificationQualifierCode qualifying the reference identification.D | 2000A | PRV02 | - | 128 ................ 80D | 2010AA | REF01 | - | 128 ................ 90D | 2010AC | REF01 | - | 128 .............. 104D | 2010AC | REF01 | - | 128 .............. 106D | 2010BA | REF01 | - | 128 .............. 120D | 2010BA | REF01 | - | 128 .............. 121D | 2010BB | REF01 | - | 128 .............. 127D | 2010BB | REF01 | - | 128 .............. 129D | 2010CA | REF01 | - | 128 .............. 142D | 2300 | REF01 | - | 128 .............. 161D | 2300 | REF01 | - | 128 .............. 163D | 2300 | REF01 | - | 128 .............. 164D | 2300 | REF01 | - | 128 .............. 166D | 2300 | REF01 | - | 128 .............. 167D | 2300 | REF01 | - | 128 .............. 168D | 2300 | REF01 | - | 128 .............. 169D | 2300 | REF01 | - | 128 .............. 170D | 2300 | REF01 | - | 128 .............. 172D | 2300 | REF01 | - | 128 .............. 173D | 2300 | REF01 | - | 128 .............. 174D | 2300 | REF01 | - | 128 .............. 175D | 2310A | PRV02 | - | 128 .............. 322D | 2310A | REF01 | - | 128 .............. 324D | 2310B | REF01 | - | 128 .............. 329D | 2310C | REF01 | - | 128 .............. 334D | 2310D | REF01 | - | 128 .............. 339D | 2310E | REF01 | - | 128 .............. 347D | 2310F | REF01 | - | 128 .............. 352D | 2330A | REF01 | - | 128 .............. 383D | 2330B | REF01 | - | 128 .............. 390


MAY 2006 E.15

D | 2330B | REF01 | - | 128 .............. 392D | 2330B | REF01 | - | 128 .............. 393D | 2330B | REF01 | - | 128 .............. 394D | 2330B | REF01 | - | 128 .............. 395D | 2330C | REF01 | - | 128 .............. 398D | 2330C | REF01 | - | 128 .............. 398D | 2330D | REF01 | - | 128 .............. 402D | 2330E | REF01 | - | 128 .............. 406D | 2330F | REF01 | - | 128 .............. 410D | 2330G | REF01 | - | 128 .............. 414D | 2330H | REF01 | - | 128 .............. 418D | 2330I | REF01 | - | 128 .............. 422D | 2400 | REF01 | - | 128 .............. 435D | 2400 | REF01 | - | 128 .............. 437D | 2400 | REF01 | - | 128 .............. 438D | 2410 | REF01 | - | 128 .............. 454D | 2420A | REF01 | - | 128 .............. 459D | 2420A | REF04 | C040-1 | 128 .............. 460D | 2420B | REF01 | - | 128 .............. 464D | 2420B | REF04 | C040-1 | 128 .............. 465D | 2420C | REF01 | - | 128 .............. 469D | 2420C | REF04 | C040-1 | 128 .............. 470D | 2420D | REF01 | - | 128 .............. 474D | 2420D | REF04 | C040-1 | 128 .............. 475

REFERRAL NUMBER

Referral NumberReferral authorization number.D | 2300 | REF02 | - | 127 .............. 163

REFERRING PROVIDER FIRST NAME

Referring Provider First NameThe first name of provider who referred thepatient to the provider of service on this claim.D | 2310F | NM104 | - | 1036 ............ 350D | 2420D | NM104 | - | 1036 ............ 472

REFERRING PROVIDER IDENTIFIER

Referring Provider IdentifierThe identification number for the referringphysician.D | 2310F | NM109 | - | 67 ................ 351D | 2420D | NM109 | - | 67 ................ 473

REFERRING PROVIDER LAST NAME

Referring Provider Last NameThe Last Name of Provider who referred thepatient to the provider of service on this claim.D | 2310F | NM103 | - | 1035 ............ 350D | 2420D | NM103 | - | 1035 ............ 472

REFERRING PROVIDER MIDDLE NAME OR INITIAL

Referring Provider MiddleName or InitialMiddle name or initial of the provider who isreferring patient for care.D | 2310F | NM105 | - | 1037 ............ 350D | 2420D | NM105 | - | 1037 ............ 472

REFERRING PROVIDER NAME SUFFIX

Referring Provider Name SuffixSuffix to the name of the provider referring thepatient for care.D | 2310F | NM107 | - | 1039 ............ 350D | 2420D | NM107 | - | 1039 ............ 472

REFERRING PROVIDER SECONDARY IDENTIFIER

Referring Provider SecondaryIdentifierAdditional identification number for the providerreferring the patient for service.D | 2310F | REF02 | - | 127 .............. 353D | 2420D | REF02 | - | 127 .............. 475

REIMBURSEMENT RATE

Reimbursement RateRate used when payment is based upon apercentage of applicable charges.D | 2320 | MOA01 | - | 954 .............. 374

REJECT REASON CODE

Reject Reason CodeCode assigned by issuer to identify reason forrejection.D | 2300 | HCP13 | - | 901 .............. 317D | 2400 | HCP13 | - | 901 .............. 447

RELEASE OF INFORMATION CODE

Release of Information CodeCode indicating whether the provider has on filea signed statement permitting the release ofmedical data to other organizations.D | 2300 | CLM09 | - | 1363 ............ 147D | 2320 | OI06 | - | 1363 ............ 368

REMAINING PATIENT LIABILITY

Remaining Patient LiabilityIn the judgement of the provider, the amountthat remained to be paid after adjudication bythis Other Payer.D | 2320 | AMT02 | - | 782 .............. 365D | 2430 | AMT02 | - | 782 .............. 487

RENDERING PROVIDER FIRST NAME

Rendering Provider First NameThe first name of the provider who performedthe service.D | 2310D | NM104 | - | 1036 ............ 337D | 2420C | NM104 | - | 1036 ............ 467

RENDERING PROVIDER IDENTIFIER

Rendering Provider IdentifierThe identifier assigned by the Payor to theprovider who performed the service.D | 2310D | NM109 | - | 67 ................ 338D | 2420C | NM109 | - | 67 ................ 468

RENDERING PROVIDER LAST NAME

Rendering Provider Last NameThe last name of the provider who performedthe service.D | 2310D | NM103 | - | 1035 ............ 337D | 2420C | NM103 | - | 1035 ............ 467

RENDERING PROVIDER MIDDLE NAME OR INITIAL

Rendering Provider MiddleName or InitialMiddle name or initial of the provider who hasprovided the services to the patient.D | 2310D | NM105 | - | 1037 ............ 337D | 2420C | NM105 | - | 1037 ............ 467

RENDERING PROVIDER NAME SUFFIX


E.16 MAY 2006

Rendering Provider Name SuffixName suffix of the provider who has providedthe services to the patient.D | 2310D | NM107 | - | 1039 ............ 337D | 2420C | NM107 | - | 1039 ............ 467

RENDERING PROVIDER SECONDARY IDENTIFIER

Rendering Provider SecondaryIdentifierAdditional identifier for the provider providingcare to the patient.D | 2310D | REF02 | - | 127 .............. 340D | 2420C | REF02 | - | 127 .............. 470

REPRICED ALLOWED AMOUNT

Repriced Allowed AmountThe maximum amount determined by therepricer as being allowable under the provisionsof the contract prior to the determination of theactual payment.D | 2300 | HCP02 | - | 782 .............. 314

REPRICED APPROVED AMOUNT

Repriced Approved AmountThe amount allowed by the repricer for theclaim or service line net of adjustments.D | 2300 | HCP07 | - | 782 .............. 315

REPRICED APPROVED DRG CODE

Repriced Approved DRG CodeThe Diagnosis Related Group approved by therepricer for payment for this claimD | 2300 | HCP06 | - | 127 .............. 315

REPRICED APPROVED HCPCS CODE

Repriced Approved HCPCSCodeThe HCPCS code that describes the servicesas approved by the repricer.D | 2400 | HCP10 | - | 234 .............. 446

REPRICED APPROVED REVENUE CODE

Repriced Approved RevenueCodeUB92 revenue code approved by the repricerfor payment on the claim.D | 2300 | HCP08 | - | 234 .............. 316

REPRICED APPROVED SERVICE UNIT COUNT

Repriced Approved ServiceUnit CountNumber of service units approved by pricing orrepricing entity.D | 2300 | HCP12 | - | 380 .............. 316

REPRICED CLAIM REFERENCE NUMBER

Repriced Claim ReferenceNumberIdentification number, assigned by a repricingorganization, to identify the claim.D | 2300 | REF02 | - | 127 .............. 167

REPRICED LINE ITEM REFERENCE NUMBER

Repriced Line Item ReferenceNumberIdentification number of a line item repriced by athird party or prior payer.D | 2400 | REF02 | - | 127 .............. 437

REPRICED SAVING AMOUNT

Repriced Saving AmountThe amount of savings related to Third PartyOrganization claims.D | 2300 | HCP03 | - | 782 .............. 314

REPRICER RECEIVED DATE

Repricer Received DateDate the claim was received by the repricerorganization.D | 2300 | DTP03 | - | 1251 ............ 152

REPRICING ORGANIZATION IDENTIFIER

Repricing OrganizationIdentifierReference or identification number of therepricing organization.D | 2300 | HCP04 | - | 127 .............. 315

REPRICING PER DIEM OR FLAT RATE AMOUNT

Repricing Per Diem or Flat RateAmountAmount used to determine the flat rate or perdiem price by the repricing organization.D | 2300 | HCP05 | - | 118............... 315

SERVICE AUTHORIZATION EXCEPTION CODE

Service AuthorizationException CodeCode identifying the service authorizationexception.D | 2300 | REF02 | - | 127 .............. 161

SERVICE DATE

Service DateDate of service, such as the start date of theservice, the end date of the service, or thesingle day date of the service.D | 2400 | DTP03 | - | 1251 ............ 434

SERVICE LINE PAID AMOUNT

Service Line Paid AmountAmount paid by the indicated payer for aservice lineD | 2430 | SVD02 | - | 782 .............. 477

SERVICE LINE REVENUE CODE

Service Line Revenue CodeUB92 Revenue Code pertaining to the serviceline.D | 2400 | SV201 | - | 234 .............. 424

SERVICE TAX AMOUNT

Service Tax AmountThe amount of service tax or surchargeapplicable to the reported service.D | 2400 | AMT02 | - | 782 .............. 439

SERVICE UNIT COUNT


MAY 2006 E.17

Service Unit CountThe quantity of units, times, days, visits,services, or treatments for the service describedby the HCPCS codes, revenue code orprocedure code.D | 2400 | SV205 | - | 380 .............. 428

STATEMENT FROM AND TO DATE

Statement From and To DateThe date of the start or end of the periodcovered on the claim.D | 2300 | DTP03 | - | 1251 ............ 150

SUBMITTER CONTACT NAME

Submitter Contact NameName of the person at the submitterorganization to whom inquiries about thetransaction should be directed.H | 1000A | PER02 | - | 93 .................. 74

SUBMITTER FIRST NAME

Submitter First NameThe first name of the person submitting thetransaction or receiving the transaction, asidentified by the preceding identification code.H | 1000A | NM104 | - | 1036 .............. 72

SUBMITTER IDENTIFIER

Submitter IdentifierCode or number identifying the entity submittingthe claim.H | 1000A | NM109 | - | 67 .................. 72

SUBMITTER LAST OR ORGANIZATION NAME

Submitter Last or OrganizationNameThe last name or the organizational name of theentity submitting the transactionH | 1000A | NM103 | - | 1035 .............. 72

SUBMITTER MIDDLE NAME OR INITIAL

Submitter Middle Name or InitialThe middle name or initial of the personsubmitting the transaction.H | 1000A | NM105 | - | 1037 .............. 72

SUBSCRIBER ADDRESS LINE

Subscriber Address LineAddress line of the current mailing address ofthe insured individual or subscriber to thecoverage.D | 2010BA | N301 | - | 166 ...............115D | 2010BA | N302 | - | 166 ...............115

SUBSCRIBER BIRTH DATE

Subscriber Birth DateThe date of birth of the subscriber to theindicated coverage or policy.D | 2010BA | DMG02 | - | 1251 .............118

SUBSCRIBER CITY NAME

Subscriber City NameThe City Name of the insured individual orsubscriber to the coverage.D | 2010BA | N401 | - | 19 .................116

SUBSCRIBER FIRST NAME

Subscriber First NameThe first name of the insured individual orsubscriber to the coverage.D | 2010BA | NM104 | - | 1036 .............113

SUBSCRIBER GENDER CODE

Subscriber Gender CodeCode indicating the sex of the subscriber to theindicated coverage or policy.D | 2010BA | DMG03 | - | 1068 .............119

SUBSCRIBER GROUP NAME

Subscriber Group NameName of the group through which the coverageis provided to the subscriber.D | 2000B | SBR04 | - | 93 .................110

SUBSCRIBER GROUP OR POLICY NUMBER

Subscriber Group or PolicyNumberThe identifier assigned by the health plan oradministrator to identify the group throughwhich the coverage is provided to the subscriber.D | 2000B | SBR03 | - | 127 ...............110

SUBSCRIBER LAST NAME

Subscriber Last NameThe surname of the insured individual orsubscriber to the coverage.D | 2010BA | NM103 | - | 1035 .............113

SUBSCRIBER MIDDLE NAME OR INITIAL

Subscriber Middle Name orInitialThe middle name or initial of the subscriber tothe indicated coverage or policy.D | 2010BA | NM105 | - | 1037 .............113

SUBSCRIBER NAME SUFFIX

Subscriber Name SuffixSuffix of the insured individual or subscriber tothe coverage.D | 2010BA | NM107 | - | 1039 .............113

SUBSCRIBER POSTAL ZONE OR ZIP CODE

Subscriber Postal Zone or ZIPCodeThe ZIP Code of the insured individual orsubscriber to the coverage.D | 2010BA | N403 | - | 116................117

SUBSCRIBER PRIMARY IDENTIFIER

Subscriber Primary IdentifierPrimary identification number of the subscriberto the coverage.D | 2010BA | NM109 | - | 67 .................114

SUBSCRIBER STATE CODE

Subscriber State CodeThe State Postal Code of the insured individualor subscriber to the coverage.D | 2010BA | N402 | - | 156 ...............116

SUBSCRIBER SUPPLEMENTAL IDENTIFIER


E.18 MAY 2006

Subscriber SupplementalIdentifierIdentifies another or additional distinguishingcode number associated with the subscriber.D | 2010BA | REF02 | - | 127 .............. 120

TERMS DISCOUNT PERCENTAGE

Terms Discount PercentageDiscount percentage available to the payer forpayment within a specific time period.D | 2300 | CN105 | - | 338 .............. 159

TOTAL CLAIM CHARGE AMOUNT

Total Claim Charge AmountThe sum of all charges included within thisclaim.D | 2300 | CLM02 | - | 782 .............. 145

TRANSACTION SEGMENT COUNT

Transaction Segment CountA tally of all segments between the ST and theSE segments including the ST and SEsegments.D | | SE01 | - | 96 ................ 488

TRANSACTION SET CONTROL NUMBER

Transaction Set ControlNumberThe unique identification number within atransaction set.H | | ST02 | - | 329 ................ 67D | | SE02 | - | 329 .............. 488

TRANSACTION SET CREATION DATE

Transaction Set Creation DateIdentifies the date the submitter created thetransaction.H | | BHT04 | - | 373 ................ 69

TRANSACTION SET CREATION TIME

Transaction Set Creation TimeTime file is created for transmission.H | | BHT05 | - | 337 ................ 69

TRANSACTION SET IDENTIFIER CODE

Transaction Set Identifier CodeCode uniquely identifying a Transaction Set.H | | ST01 | - | 143 ................ 67

TRANSACTION SET PURPOSE CODE

Transaction Set Purpose CodeCode identifying purpose of transaction set.H | | BHT02 | - | 353 ................ 68

TREATMENT CODE

Treatment CodeCodes describing the treatment ordered by thephysician.D | 2300 | HI01 | C022-2 | 1271 ............ 305D | 2300 | HI02 | C022-2 | 1271 ............ 305D | 2300 | HI03 | C022-2 | 1271 ............ 306D | 2300 | HI04 | C022-2 | 1271 ............ 307D | 2300 | HI05 | C022-2 | 1271 ............ 307D | 2300 | HI06 | C022-2 | 1271 ............ 308D | 2300 | HI07 | C022-2 | 1271 ............ 309D | 2300 | HI08 | C022-2 | 1271 ............ 309D | 2300 | HI09 | C022-2 | 1271 ............ 310

D | 2300 | HI10 | C022-2 | 1271 .............311D | 2300 | HI11 | C022-2 | 1271 .............311D | 2300 | HI12 | C022-2 | 1271 ............ 312

UNIT OR BASIS FOR MEASUREMENT CODE

Unit or Basis for MeasurementCodeCode specifying the units in which a value isbeing expressed, or manner in which ameasurement has been taken.D | 2300 | HCP11 | - | 355 .............. 316D | 2400 | SV204 | - | 355 .............. 428D | 2400 | HCP11 | - | 355 .............. 447

VALUE ADDED NETWORK TRACE NUMBER

Value Added Network TraceNumberUnique Identification number for a transactionassigned by a Value Added Network,Clearinghouse, or other transmission entity.D | 2300 | REF02 | - | 127 .............. 171

VALUE CODE

Value CodeA code that identifies data of a monetary naturethat is necessary for processing this claim asrequired by the payer organization.D | 2300 | HI01 | C022-2 | 1271 ............ 284D | 2300 | HI02 | C022-2 | 1271 ............ 285D | 2300 | HI03 | C022-2 | 1271 ............ 286D | 2300 | HI04 | C022-2 | 1271 ............ 287D | 2300 | HI05 | C022-2 | 1271 ............ 288D | 2300 | HI06 | C022-2 | 1271 ............ 288D | 2300 | HI07 | C022-2 | 1271 ............ 289D | 2300 | HI08 | C022-2 | 1271 ............ 290D | 2300 | HI09 | C022-2 | 1271 ............ 291D | 2300 | HI10 | C022-2 | 1271 ............ 291D | 2300 | HI11 | C022-2 | 1271 ............ 292D | 2300 | HI12 | C022-2 | 1271 ............ 293

VALUE CODE AMOUNT

Value Code AmountAmount associated with the value codereported in this composite element.D | 2300 | HI01 | C022-5 | 782 .............. 285D | 2300 | HI02 | C022-5 | 782 .............. 285D | 2300 | HI03 | C022-5 | 782 .............. 286D | 2300 | HI04 | C022-5 | 782 .............. 287D | 2300 | HI05 | C022-5 | 782 .............. 288D | 2300 | HI06 | C022-5 | 782 .............. 288D | 2300 | HI07 | C022-5 | 782 .............. 289D | 2300 | HI08 | C022-5 | 782 .............. 290D | 2300 | HI09 | C022-5 | 782 .............. 291D | 2300 | HI10 | C022-5 | 782 .............. 291D | 2300 | HI11 | C022-5 | 782 .............. 292D | 2300 | HI12 | C022-5 | 782 .............. 293

VERSION,, RELEASE,, OR INDUSTRY IDENTIFIER

Version, Release, or IndustryIdentifierCode indicating the version, release,sub-release and industry identification of theEDI standard being used.H | | ST03 | - | 1705 .............. 67


MAY 2006 E.19


E.20 MAY 2006

3 Examples• Please visit http://www.wpc-edi.com/837 for additional or corrected

examples.

3.1 Professional

3.1.1 Example 1 - Commercial Health InsurancePatient is a different person than the Subscriber. Payer is commercial health insurancecompany.

SUBSCRIBER: Jane SmithPATIENT ADDRESS:236 N. Main St., Miami, Fl, 33413TELEPHONE NUMBER: 305-555-1111SEX: FDOB: 05/01/43EMPLOYER: ACME Inc.GROUP #: 2222-SJKEY INSURANCE COMPANY ID #: JS00111223333

PATIENT: Ted SmithPATIENT ADDRESS:236 N. Main St., Miami, Fl, 33413TELEPHONE NUMBER: 305-555-1111SEX: MDOB: 05/01/73KEY INSURANCE COMPANY ID #: JS01111223333

DESTINATION PAYER: Key Insurance CompanyPAYER ADDRESS: 3333 Ocean St. South Miami, FL 33000PAYER ID: 999996666

SUBMITTER: Premier Billing ServiceEDI#: TGJ23CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231

RECEIVER: Key Insurance CompanyEDI #:66783JJT

497MAY 2006

005010X222 • 837HEALTH CARE CLAIM: PROFESSIONAL


bclore

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and does not have a unique payer-assigned identifier.

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BILLING PROVIDER: Dr. Ben Kildare,ADDRESS: 234 Seaway St, Miami, FL, 33111NPI: 9876543210TIN: 587654321KEY INSURANCE COMPANY PROVIDER ID #: KA6663Taxonomy Code: 203BF0100Y

PAY-TO PROVIDER: Kildare Associates,PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111

RENDERING PROVIDER: Dr. Ben Kildare

PATIENT ACCOUNT NUMBER: 2-646-3774CASE: Patient has sore throat.

INITIAL VISIT: DOS=10/03/06. POS=OfficeSERVICES: Office visit, intermediate service, established patient, throat culture.CHARGES: Office first visit = $40.00, Lab test for strep = $15.00

FOLLOW-UP VISIT: DOS=10/10/06 POS=OfficeAntibiotics didn’t work (pain continues).SERVICES: Office visit, intermediate service, established patient, mono screening.CHARGES: Follow-up visit = $35.00, lab test for mono = $10.00.

TOTAL CHARGES: $100.00.

ELECTRONIC ROUTE: Billing provider (sender), to VAN to Key Insurance Company(receiver). VAN claim identification number = 17312345600006351.


HEADER


ST*837*0021*005010X222~

1


BHT*0019*00*244579*20061015*1023*CH~

2

1000A SUBMITTER

NM1 SUBMITTER NAME

NM1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~

3

MAY 2006498



bclore

Callout

005010X291

bclore

Highlight

bclore

Callout

Predetermination request. Today's date assumed.

bclore

Highlight

bclore

Callout

for predetermination request

bclore

Callout

$45.00

bclore

Highlight



PER*IC*JERRY*TE*3055552222*EX*231~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*KEY INSURANCE COMPANY*****46*66783JJT~

5


HL - BILLING PROVIDER

HL*1**20*1~

6

PRV BILLING PROVIDER SPECIALTY INFORMATION

PRV*BI*PXC*203BF0100Y~

7



NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~

8


N3*234 SEAWAY ST~

9


N4*MIAMI*FL*33111~

10

REF - BILLING PROVIDER TAX IDENTIFICATION

REF*EI*587654321~

11

2010AB PAY-TO PROVIDER

NM1 PAY-TO PROVIDER NAME

NM1*87*2~

12

N3 PAY-TO PROVIDER ADDRESS

N3*2345 OCEAN BLVD~

13

N4 PAY-TO PROVIDER CITY

N4*MAIMI*FL*33111~

14


HL - SUBSCRIBER

HL*2*1*22*1~

15

499MAY 2006





SBR*P**2222-SJ******CI~

16

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JANE****MI*JS00111223333~

17


DMG*D8*19430501*F~

18

2010BB PAYER

NM1 PAYER NAME

NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~

19


REF*G2*KA6663~

20


HL - PATIENT

HL*3*2*23*0~

21


PAT*19~

22

2010CA PATIENT

NM1 PATIENT NAME

NM1*QC*1*SMITH*TED~

23

N3 PATIENT ADDRESS

N3*236 N MAIN ST~

24

N4 PATIENT CITY/STATE/ZIP

N4*MIAMI*FL*33413~

25


DMG*D8*19730501*M~

26

2300 CLAIM


CLM*26463774*100***11:B:1*Y*A*Y*I~

27

MAY 2006500



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CLM*26463774*45***11:B:1*Y*A*Y*I**********08~


REF CLAIM IDENTIFICATION NUMBER FOR CLEARING HOUSES (Added by C.H.)

REF*D9*17312345600006351~

28


HI*BK:0340*BF:V7389~

29

2400 SERVICE LINE


LX*1~

30

SV1 PROFESSIONAL SERVICE

SV1*HC:99213*40*UN*1***1~

31

DTP DATE - SERVICE DATE(S)

DTP*472*D8*20061003~

32

2400 SERVICE LINE


LX*2~

33


SV1*HC:87070*15*UN*1***1~

34


DTP*472*D8*20061003~

35

2400 SERVICE LINE


LX*3~

36


SV1*HC:99214*35*UN*1***2~

37


DTP*472*D8*20061010~

38

2400 SERVICE LINE


LX*4~

39

501MAY 2006



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SV1*HC:86663*10*UN*1***2~

40


DTP*472*D8*20061010~

41

TRAILER


SE*42*0021~

42


M1*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE

*3055552222*EX*231~NM1*40*2*KEY INSURANCE COMPANY*****46*667

83JJT~HL*1**20*1~PRV*BI*PXC*203BF0100Y~NM1*85*2*BEN KILDARE

SERVICE*****XX*9876543210~N3*234 SEAWAY ST~N4*MIAMI*FL*33111

~REF*EI*587654321~NM1*87*2~N3*2345 OCEAN BLVD~N4*MAIMI*FL*33

111~HL*2*1*22*1~SBR*P**2222-SJ******CI~NM1*IL*1*SMITH*JANE**

**MI*JS00111223333~DMG*D8*19430501*F~NM1*PR*2*KEY INSURANCE

COMPANY*****PI*999996666~REF*G2*KA6663~HL*3*2*23*0~PAT*19~NM

1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*1

9730501*M~CLM*26463774*100***11:B:1*Y*A*Y*I~REF*D9*173123456

00006351~HI*BK:0340*BF:V7389~LX*1~SV1*HC:99213*40*UN*1***1~D

TP*472*D8*20061003~LX*2~SV1*HC:87070*15*UN*1***1~DTP*472*D8*

20061003~LX*3~SV1*HC:99214*35*UN*1***2~DTP*472*D8*20061010~L

X*4~SV1*HC:86663*10*UN*1***2~DTP*472*D8*20061010~SE*42*0021~

3.1.2 Example 2 - EncounterPatient is the same person as the Subscriber. Payer is an HMO. Encounter is transmittedthrough a clearinghouse. Submitter is the billing provider, receiver is a payer.

SUBSCRIBER/PATIENT: Ted SmithADDRESS: 236 N. Main St., Miami, Fl, 33413,TELEPHONE NUMBER: 305-555-1111SEX: MDOB: 05/01/43EMPLOYER: ACME Inc.GROUP #: 12312-A

MAY 2006502



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005010X291

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CLM*26463774*45***11:B:1*Y*A*Y*I**********08

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HMO Plan

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Predetermination request

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PAYER ID NUMBER: SSNSSN: 000-22-1111

DESTINATION PAYER: Alliance Health and Life Insurance Company (AHLIC),PAYER ADDRESS: 2345 West Grand Blvd, Detroit, MI 48202. ,AHLIC #: 741234

SUBMITTER: Premier Billing ServiceEDI#: TGJ23CONTACT PERSON AND PHONE NUMBER: JERRY, 305-555-2222 ext. 231

RECEIVER: Alliance Health and Life Insurance Company (AHLIC),EDI #: 66783JJT

BILLING PROVIDER: Dr. Ben Kildare,ADDRESS: 234 Seaway St, Miami, FL, 33111NPI: 9876543210TIN: 587654321Taxonomy Code: 203BF0100Y

PAY-TO PROVIDER: Kildare Associates,PROVIDER ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111

RENDERING PROVIDER: Dr. Ben Kildare/Family Practitioner

PATIENT ACCOUNT NUMBER: 2-646-2967CASE: Patient has sore throat.

INITIAL VISIT: DOS=10/03/06. POS=OfficeSERVICES: Office visit, intermediate service, established patient, throat culture.CHARGES: Office first visit = $40.00, Lab test for strep = $15.00

FOLLOW-UP VISIT: DOS=10/10/06 POS=OfficeAntibiotics didn’t work (pain continues).SERVICES: Office visit, intermediate service, established patient, mono screening.CHARGES: Follow-up visit = $35.00, lab test for mono = $10.00.

TOTAL CHARGES: $100.00.

ELECTRONIC ROUTE: Billing provider (sender) to Clearinghouse to Alliance Healthand Life Insurance Company (AHLIC);Clearinghouse claim identification number = 17312345600006351.

503MAY 2006



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$45.00

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Predetermination request. Today's date assumed.

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for predetermination request


HEADER


ST*837*0021*005010X222~

1


BHT*0019*00*0123*20061015*1023*RP~

2

1000A SUBMITTER

NM1 SUBMITTER NAME


3


PER*IC*JERRY*TE*3055552222*EX*231~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2* AHLIC*****46*66783JJT~

5



HL*1**20*1~

6

PRV BILLING PROVIDER SPECIALTY INFORMATION

PRV*BI*PXC*203BF0100Y~

7



NM1*85*2*BEN KILDARE SERVICE*****XX*9876543210~

8


N3*234 SEAWAY ST~

9


N4*MIAMI*FL*33111~

10


REF*EI*587654321~

11



NM1*87*2~

12

MAY 2006504



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005010X291

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N3*2345 OCEAN BLVD~

13


N4*MIAMI*FL*33111~

14


HL - SUBSCRIBER

HL*2*1*22*0~

15


SBR*P*18*12312-A******HM~

16

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*TED****MI*000221111~

17


N3*236 N MAIN ST~

18

N4 SUBSCRIBER CITY

N4*MIAMI*FL*33413~

19


DMG*D8*19430501*M~

20

2010BB SUBSCRIBER/PAYER

NM1 PAYER NAME

NM1*PR*2*ALLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~

21

2300 CLAIM


CLM*26462967*100***11:B:1*Y*A*Y*I~

22

DTP DATE OF ONSET

DTP*431*D8*19981003~

23

REF CLEARING HOUSE CLAIM NUMBER (Added by CH)

REF*D9*17312345600006351~

24

505MAY 2006



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CLM*26462967*45***11:B:1*Y*A*Y*I**********08

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HI*BK:0340*BF:V7389~

25

2310D SERVICE LOCATION

NM1 SERVICE FACILITY LOCATION

NM1*77*2*KILDARE ASSOCIATES*****XX*5812345679~

26

N3 SERVICE FACILITY ADDRESS

N3*2345 OCEAN BLVD~

27

N4 SERVICE FACILITY CITY/STATE/ZIP

N4*MIAMI*FL*33111~

28

2400 SERVICE LINE


LX*1~

29


SV1*HC:99213*40*UN*1***1~

30


DTP*472*D8*20061003~

31

2400 SERVICE LINE


LX*2~

32


SV1*HC:87072*15*UN*1***1~

33


DTP*472*D8*20061003~

34

2400 SERVICE LINE


LX*3~

35


SV1*HC:99214*35*UN*1***2~

36

MAY 2006506



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DTP*472*D8*20061010~

37

2400 SERVICE LINE


LX*4~

38


SV1*HC:86663*10*UN*1***2~

39


DTP*472*D8*20061010~

40

TRAILER


SE*41*0021~

41

Complete Data String:ST*837*0021*005010X222~BHT*0019*00*0123*20061015*1023*RP~NM1

*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3

055552222*EX*231~NM1*40*2*AHLIC*****46*66783JJT~HL*1**20*1~P

RV*BI*PXC*203BF0100Y~NM1*85*2*BEN KILDARE SERVICE*****XX*987

6543210~N3*234 SEAWAY ST~N4*MIAMI*FL*33111~REF*EI*587654321~

NM1*87*2~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~HL*2*1*22*0~SB

R*P*18*12312-A******HM~NM1*IL*1*SMITH*TED****MI*00221111~N3*

236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19430501*M~NM1*PR*2*A

LLIANCE HEALTH AND LIFE INSURANCE*****PI*741234~CLM*26462967

*100***11:B:1*Y*A*Y*I~DTP*431*D8*19981003~REF*D9*17312345600

006351~HI*BK:0340*BF:V7389~NM1*77*2*KILDARE ASSOCIATES*****X

X*5812345679~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~LX*1~SV1*H

C:99213*40*UN*1***1~DTP*472*D8*20061003~LX*2~SV1*HC:87072*15

*UN*1***1~DTP*472*D8*20061003~LX*3~SV1*HC:99214*35*UN*1***2~

DTP*472*D8*20061010~LX*4~SV1*HC:86663*10*UN*1***2~DTP*472*D8

*20061010~SE*41*0021~

507MAY 2006



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005010X291

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CLM*26462967*45***11:B:1*Y*A*Y*I**********08

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3.1.3 Example 3 - Coordination of benefits (COB)Coordination of benefits; patient is not the subscriber; payers are commercial healthinsurance companies. Patient and subscriber have same primary policy number. Claimsubmitted to primary insurer with information pertaining to the secondary payer.

SUBSCRIBER FOR PAYER A: Jane SmithADDRESS: 236 N. Main St., Miami, Fl 33413TELEPHONE NUMBER: 305-555-1111SEX: FDOB: 05/01/43EMPLOYER: Acme, Inc.PAYER A ID NUMBER: JS00111223333SSN: 111-22-3333

SUBSCRIBER FOR PAYER B: Jack SmithADDRESS: 236 N. Main St., Miami, Fl 33413TELEPHONE NUMBER: 305-555-1111SEX: MDOB: 10/22/43EMPLOYER: Telecom of FloridaPAYER B ID NUMBER: T55TY666SSN: 222-33-4444

PATIENT: Ted SmithADDRESS: 236 N. Main St., Miami, Fl 33413TELEPHONE NUMBER: 305-555-1111SEX: MDOB: 05/01/73PAYER A ID NUMBER: JS01111223333PAYER B ID NUMBER: T55TY666-01SSN: 000-22-1111

DESTINATION PAYER A: Key Insurance CompanyPAYER A ADDRESS: 3333 Ocean St., South Miami, FL, 33000PAYER A ID NUMBER: (TIN) 999996666

RECEIVER FOR PAYER A: XYZ REPRICEREDI #: 66783JJT

RECEIVER: Alliance Health and Life Insurance Company (AHLIC),

MAY 2006508



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EDI #: 66783JJT

DESTINATION PAYER B (RECEIVER): Great Prairies HealthPAYER B ADDRESS: 4456 South Shore Blvd., Chicago, IL 44444PAYER B ID NUMBER: 567890EDI #: 567890

BILLING PROVIDER/SENDER: Dr. Ben KildareADDRESS: 234 Seaway St, Miami, FL, 33111PAYER A ID NUMBER: KA6663PAYER B ID NUMBER: 88877TIN: 999996666EDI # FOR RECEIVER A: TGJ23EDI # FOR PAYER B: 12EEER000TY

PAY-TO PROVIDER: Kildare Associates,ADDRESS: 2345 Ocean Blvd, Miami, Fl 33111PAYER A ID NUMBER: 99878ABAPAYER B ID NUMBER: EX7777TIN: 581234567

RENDERING PROVIDER: Dr. Ben KildarePAYER A ID NUMBER: KA6663PAYER B ID NUMBER: 88877TIN: 999996666

PATIENT ACCOUNT NUMBER: 26407789CASE: Patient came to office for routine hyperlipidemia check. DOS=10/03/05,POS=Office; Patient also complained of hay fever and heart burn.SERVICES RENDERED: Patient received injection for hyperlipidemia and hay fever.CHARGES: Patient was charged for office visit ($43.00), and two injections ($15.00 and$21.04).

ELECTRONIC PATH: The billing provider (sender) transmits the claim to Payer A(receiver) (Example 3.A) who adjudicates the claim. Payer A transmits back an 835 tothe billing provider.The billing provider then submits a second claim to Payer B (receiver)(Example 3.B).

509MAY 2006



3.1.3.1 Example 3.A -- Claim from Billing Provider to Payer A


HEADER


ST*837*0021*005010X222~

1


BHT*0019*00*0123*20051015*1023*CH~

2

1000A SUBMITTER

NM1 SUBMITTER NAME


3


PER*IC*JERRY*TE*3055552222~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*XYZ REPRICER*****46*66783JJT~

5



HL*1**20*1~

6



NM1*85*1*KILDARE*BEN****XX*1999996666~

7


N3*1234 SEAWAY ST~

8

N4 BILLING PROVIDER CITY/STATE/ZIP

N4*MIAMI*FL*33111~

9


REF*EI*123456789~

10

PER BILLING PROVIDER CONTACT INFORMATION

PER*IC*CONNIE*TE*3055551234~

11

MAY 2006510






NM1*87*2~

12


N3*2345 OCEAN BLVD~

13

N4 PAY-TO PROVIDER CITY/STATE/ZIP

N4*MIAMI*FL*33111~

14


HL - SUBSCRIBER

HL*2*1*22*1~

15


SBR*P*******CI~

16

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JANE****MI*111223333~

17


DMG*D8*19430501*F~

18

2010BB PAYER

NM1 PAYER NAME


19

N3 PAYER ADDRESS

N3*3333 OCEAN ST~

20

N4 PAYER CITY/STATE/ZIP

N4*SOUTH MIAMI*FL*33000~

21


REF*G2*PBS3334~

22


HL - PATIENT

HL*3*2*23*0~

23

511MAY 2006





PAT*19~

24

2010CA PATIENT

NM1 PATIENT NAME

NM1*QC*1*SMITH*TED~

25

N3 PATIENT ADDRESS

N3*236 N MAIN ST~

26


N4*MIAMI*FL*33413~

27


DMG*D8*19730501*M~

28

2300 CLAIM


CLM*26407789*79.04***11:B:1*Y*A*Y*I*P~

29


HI*BK:4779*BF:2724*BF:2780*BF:53081~

30

2310B RENDERING PROVIDER

NM1 RENDERING PROVIDER NAME

NM1*82*1*KILDARE*BEN****XX*1999996666~

31

PRV RENDERING PROVIDER INFORMATION

PRV*PE*PXC*204C00000X~

32

REF RENDERING PROVIDER SECONDARY IDENTIFICATION

REF*G2*KA6663~

33

2310D SERVICE FACILITY LOCATION



34


N3*2345 OCEAN BLVD~

35

MAY 2006512





N4*MIAMI*FL*33111~

36



SBR*S*01*******CI~

37


DMG*D8*19430501*F~

38


OI***Y*P**Y~

39



NM1*IL*1*SMITH*JACK****MI*T55TY666~

40

N3 OTHER SUBSCIBER ADDRESS

N3*236 N MAIN ST~

41

N4 OTHER SUBSCIBER CITY

N4*MIAMI*FL*33111~

42

2330B OTHER SUBSCRIBER/PAYER



43

2400 SERVICE LINE


LX*1~

44


SV1*HC:99213*43*UN*1***1:2:3:4~

45


DTP*472*D8*20051003~

46

2400 SERVICE LINE


LX*2~

47

513MAY 2006





SV1*HC:90782*15*UN*1***1:2~

48


DTP*472*D8*20051003~

49

2400 SERVICE LINE


LX*3~

50


SV1*HC:J3301*21.04*UN*1***1:2~

51


DTP*472*D8*20051003~

52

TRAILER


SE*53*0021~

53

Complete Data String For Example 3.A:ST*837*0021*005010X222~BHT*0019*00*0123*20051015*1023*CH~NM1

*41*2*PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3

055552222~NM1*40*2*XYZ REPRICER*****46*66783JJT~HL*1**20*1~N

M1*85*1*KILDARE*BEN****XX*1999996666~N3*1234 SEAWAY ST~N4*MI

AMI*FL*33111~REF*EI*123456789~PER*IC*CONNIE*TE*3055551234~NM

1*87*2~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~HL*2*1*22*1~SBR*

P*******CI~NM1*IL*1*SMITH*JANE****MI*111223333~DMG*D8*194305

01*F~NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~N3*3333

OCEAN ST~N4*SOUTH MIAMI*FL*33000~REF*G2*PBS3334~HL*3*2*23*0

~PAT*19~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*3341

3~DMG*D8*19730501*M~CLM*26407789*79.04***11:B:1*Y*A*Y*I*P~HI

*BK:4779*BF:2724*BF:2780*BF:53081~NM1*82*1*KILDARE*BEN****XX

*1999996666~PRV*PE*PXC*204C00000X~REF*G2*KA6663~NM1*77*2*KIL

DARE ASSOCIATES*****XX*1581234567~N3*2345 OCEAN BLVD~N4*MIAM

I*FL*33111~SBR*S*01*******CI~DMG*D8*19430501*F~OI***Y*P**Y~N

M1*IL*1*SMITH*JACK****MI*T55TY666~N3*236 N MAIN ST~N4*MIAMI*

FL*33111~NM1*PR*2*KEY INSURANCE COMPANY*****PI*999996666~LX*

1~SV1*HC:99213*43*UN*1***1:2:3:4~DTP*472*D8*20051003~LX*2~SV

MAY 2006514



1*HC:90782*15*UN*1***1:2~DTP*472*D8*20051003~LX*3~SV1*HC:J33

01*21.04*UN*1***1:2~DTP*472*D8*20051003~SE*53*0021~

Payer A returned an electronic remittance advice (835) to the Billing Provider with thefollowing amounts and Claim Adjustment Reason Codes:SUBMITTED CHARGES (CLP03): 79.04AMOUNT PAID (CLP04): 39.15PATIENT RESPONSIBILITY (CLP05): 36.89The CAS at the Claim level was:CAS*PR*1*21.89**2*15~ (INDICATES A $15.00 CO-INSURANCE PAYMENT AND$21.89 DEDUCTIBLE PAYMENT IS DUE FROM PATIENT).In addition, Payer A adjusted the office visit charges to $40.00 by Contractual Agreement.The CAS on line 1 was: CAS*CO*42*3~. Because the other lines did not haveadjustments, there are no CAS segments for those lines.See the Introduction for a discussion on cross walking 835s to 837s.

3.1.3.2 Example 3.B -- Claim from Billing Provider to Payer B


HEADER


ST*837*1234*005010X222~

1


BHT*0019*00*0123*20051015*1023*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*PREMIER BILLING SERVICE*****46*12EEER000TY~

3


PER*IC*JERRY*TE*3055552222~

4

1000B RECEIVER

NM1 RECEIVER

NM1*40*2*GREAT PRARIES HEALTH*****46*567890~

5



HL*1**20*1~

6

515MAY 2006





NM1 BILLING PROVIDER

NM1*85*1*KILDARE*BEN****XX*1999996666~

7


N3*1234 SEAWAY ST~

8

N4 BILLING PROVIDER CITY

N4*MIAMI*FL*33111~

9

REF - BILLING PROVIDER TAX ID

REF*EI*123456789~

10

PER BILLING CONTACT INFORMATION


11



NM1*87*2~

12


N3*2345 OCEAN BLVD~

13


N4*MIAMI*FL*33111~

14


HL - SUBSCRIBER

HL*2*1*22*1~

15


SBR*S*******CI~

16

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JACK****MI*222334444~

17


DMG*D8*19431022*M~

18

MAY 2006516




2010BB PAYER

NM1 PAYER NAME

NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*567890~

19

N3 PAYER ADDRESS

N3*4456 SOUTH SHORE BLVD~

20

N4 PAYER CITY/STATE/ZIP CODE

N4*CHICAGO*IL*44444~

21


REF*G2*567890~

22


HL - PATIENT

HL*3*2*23*0~

23


PAT*19~

24

2010CA PATIENT

NM1 PATIENT NAME

NM1*QC*1*SMITH*TED~

25

N3 PATIENT ADDRESS

N3*236 N MAIN ST~

26

N4 PATIENT CITY

N4*MIAMI*FL*33413~

27


DMG*D8*19730501*M~

28

2300 CLAIM


CLM*26407789*79.04***11:B:1*Y*A*Y*I~

29


HI*BK:4779*BF:2724*BF:2780*BF:53081~

30

517MAY 2006






NM1*82*1*KILDARE*BEN****XX*1999996666~

31



32


REF*G2*88877~

33




34


N3*2345 OCEAN BLVD~

35


N4*MIAMI*FL*33111~

36



SBR*P*01*******CI~

37

CAS CLAIM LEVEL ADJUSTMENTS AND AMOUNTS

CAS*PR*1*21.89**2*15~

38

AMT COORDINATION OF BENEFITS - PAYOR PAID AMOUNT

AMT*D*39.15~

39

AMT COORDINATION OF BENEFITS – PATIENT RESPONSBILITY

AMT*EAF*36.89~

40


DMG*D8*19430501*F~

41


OI***Y*P**Y~

42

MAY 2006518







43


N3*236 N MAIN ST~

44

N4 OTHER SUBSCIBER CITY

N4*MIAMI*FL*33111~

45




46

2400 SERVICE LINE

LX*1~

47


SV1*HC:99213*43*UN*1***1:2:3:4~

48


DTP*472*D8*20051003~

49


SVD*999996666*40*HC:99213**1~

50

CAS LINE ADJUSTMENT

CAS*CO*42*3~

51

DTP LINE ADJUDICATION DATE

DTP*573*D8*20051015~

52

2400 SERVICE LINE


LX*2~

53


SV1*HC:90782*15*UN*1***1:2~

54


DTP*472*D8*20051003~

55

519MAY 2006





SVD*999996666*15*HC:90782**1~

56


DTP*573*D8*20051015~

57

2400 SERVICE LINE


LX*3~

58


SSV1*HC:J3301*21.04*UN*1***1:2~

59


DTP*472*D8*20051003~

60


SVD*999996666*21.04*HC:J3301**1~

61


DTP*573*D8*20051015~

62

TRAILER


SE*63*1234~

63

Complete Data String For Example 3.B:ST*837*1234*005010X222~BHT*0019*00*0123*20051015*1023*CH~NM1

*41*2*PREMIER BILLING SERVICE*****46*12EEER 000TY~PER*IC*JER

RY*TE*3055552222~NM1*40*2*GREAT PRAIRIES HEALTH*****46*56789

0~HL*1**20*1~NM1*85*1*KILDARE*BEN****XX*1999996666~N3*1234 S

EAWAY ST~N4*MIAMI*FL*33111~REF*EI*123456789~ PER*IC*CONNIE*T

E*3055551234~NM1*87*2~N3*2345*OCEAN BLVD~N4*MIAMI*FL*3111~RE

F*G2*EX7777~HL*2*1*22*1~ SBR*S********CI~NM1*IL*1*SMITH*JACK

****MI*222334444~DMG*D8*19431022*M~NM1*PR*2*GREAT PRAIRIES H

EALTH*****PI*567890~N3*4456 SOUTH SHORE BLVD~N4*CHICAGO*IL*4

4444~REF*G2*567890~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH*TED~N3*

236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~CLM*264077

89*79.04***11:B:1*Y*A*Y*I~HI*BK:4779*BF:2724*BF:2780*BF:5308

1~NM1*82*1*KILDARE*BEN****XX*1999996666~PRV*PE*PXC*204C00000

MAY 2006520



X~REF*G2*88877~NM1*77*2*KILDARE ASSOCIATES*****XX*1581234567

~N3*2345 OCEAN BLVD~N4*MIAMI*FL*33111~SBR*P*01*******CI~CAS*

PR*1*21.89**2*15~AMT*D*39.15~AMT*EAF*36.89~DMG*D8*19430501*F

~OI***Y*P**Y~NM1*IL*1*SMITH*JANE****MI*JS00111223333~N3*236

N MAIN ST~N4*MIAMI*FL*33111~NM1*PR*2*KEY INSURANCE COMPANY**

***PI*999996666~LX*1~SV1*HC:99213*43*UN*1***1:2:3:4~DTP*472*

D8*20051003~SVD*999996666*40*HC:99213**1~CAS*CO*42*3~DPT*573

*D8*20051015~LX*2~SV1*HC:90782*15*UN*1***1:2~DTP*472*D8*2005

1003~SVD*999996666*15*HC:90782**1~DTP*573*D8*20051015~LX*3~S

V1*HC:J3301*21.04*UN*1***1:2~DTP*472*D8*20051003~SVD*9999966

66*21.04*HC:J3301**1~DPT*573*D8*20051015~SE*63*1234~

3.1.3.3 Example 3.C -- Claim from Payer A to Payer B inPayer-to-Payer

COB Situation. Payer A will pass the claim directly to Payer B without interventionfrom provider.If this claim were to go from the Billing Provider to Payer A and then Payer A were tosend it claim directly to Payer B, the transaction would look like this as it comes out ofPayer A’s processing system. In this situation, the Billing Provider must send Payer Aall the COB information on Payer B.


HEADER


ST*837*0024*005010X222~

1


BHT*0019*00*0123*20051015*1023*CH~

2

1000A SUBMITTER

NM1 SUBMITTER NAME

NM1*41*2*KEY INSURANCE*****46*999996666~

3


PER**IC*JERRY*TE*3055552222~

4

521MAY 2006




1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*GREAT PRARIES*****46*567890~

5



HL*1**20*1~

6


NM1 BILLING PROVIDER

NM1*85*1*KILDARE*BEN****XX*1999996666~

7


N3*1234 SEAWAY ST~

8


N4*MIAMI*FL*33111~

9

REF - BILLING PROVIDER TAX ID

REF*EI*123456789~

10



11



NM1*87*2~

12


N3*2345 OCEAN BLVD~

13

N4 PAY-TO PROVIDER CITY/STATE/ZIP

N4*MIAMI*FL*33111~

14


HL SUBSCRIBER

HL*2*1*22*1~

15


SBR*S*******CI~

16

MAY 2006522




2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JACK****MI*222334444~

17


DMG*D8*19431022*M~

18

2010BB PAYER

NM1 PAYER NAME

NM1*PR*2*GREAT PRAIRIES HEALTH*****PI*567890~

19

N3 PAYER ADDRESS

N3*4456 SOUTH SHORE BLVD~

20

N4 PAYER CITY/STATE/ZIP CODE

N4*CHICAGO*IL*44444~

21


REF*G2*EJ6666~

22


HL - PATIENT

HL*3*2*23*0~

23


PAT*19~

24

2010CA PATIENT

NM1 PATIENT NAME

NM1*QC*1*SMITH*TED~

25

N3 PATIENT ADDRESS

N3*236 N MAIN ST~

26


N4*MIAMI*FL*33413~

27


DMG*D8*19730501*M~

28

523MAY 2006




2300 CLAIM


CLM*26407789*79.04***11:B:1*Y*A*Y*I*P~

29


HI*BK:4779*BF:2724*BF:2780*BF:53081~

30



NM1*82*1*KILDARE*BEN****XX*1999996666~

31



32


REF*G2*PBS3334~

33




34


N3*2345 OCEAN BLVD~

35


N4*MIAMI*FL*33111~

36



SBR*P*01*******CI~

37


CAS*PR*1*21.89**2*15~

38

AMT COORDINATION OF BENEFITS - PAYOR PAID AMOUNT

AMT*D*39.15~

39

AMT COORDINATION OF BENEFITS – PATIENT RESPONSBILITY

AMT*EAF*36.89~

40

MAY 2006524





DMG*D8*19430501*F~

41


OI***Y*P**Y~

42




43


N3*236 N MAIN ST~

44

N4 OTHER SUBSCIBER CITY/STATE/ZIP

N4*MIAMI*FL*33111~

45




46

2330E OTHER PAYER RENDERING PROVIDER

NM1 OTHER PAYER RENDERING PROVIDER

NM1*82*1~

47

REF OTHER PAYER RENDERING PROVIDER IDENTIFICATION

REF*G2*PBS3334~

48

2400 SERVICE LINE

LX*1~

49


SV1*HC:99213*43*UN*1***1:2:3:4~

50


DTP*472*D8*20051003~

51


SVD*999996666*40*HC:99213**1~

52

CAS LINE ADJUSTMENT

CAS*CO*42*3~

53

525MAY 2006





DTP*573*D8*20051015~

54

2400 SERVICE LINE


LX*2~

55


SV1*HC:90782*15*UN*1***1:2~

56


DTP*472*D8*20051003~

57


SVD*999996666*15*HC:90782**1~

58


DTP*573*D8*20051015~

59

2400 SERVICE LINE


LX*3~

60


SV1*HC:J3301*21.04*UN*1***1:2~

61


DTP*472*D8*20051003~

62


SVD*999996666*21.04*HC:J3301**1~

63


DTP*573*D8*20051015~

64

TRAILER


SE*65*0024~

65

Complete Data String For Example 3.C:ST*837*0024*005010X222~BHT*0019*00*0123*20051015*1023*CH~NM1

MAY 2006526



*41*2*KEY INSURANCE*****46*999996666~PER*IC*JERRY*TE*3055552

222~NM1*40*2*GREAT PRAIRIES*****46*567890~HL*1**20*1~NM1*85*

1*KILDARE*BEN****XX*1999996666~N3*1234*SEAWAY ST~N4*MIAMI*FL

*33111~REF*EI*123456789~PER*IC*CONNIE*TE*3055551234~NM1*87*2

~N3*2345*OCEAN BLVD~N4*MAIMI*FL*33111~HL*2*1*22*1~SBR*S*****

**CI~NM1*IL*1*SmITH*JACK****MI*22233444~DMG*D8*19431022*M~NM

1*PR*2*GREAT PRAIRIES HEALTH*****PI*567890~N3*4456 SOUTH SHO

RE BLVD~N4*CHICAGO*IL*44444~REF*G2*EJ6666~HL*3*2*23*0~PAT*19

~NM1*QC*1*SMITH*TED~N3*236 N MAIN ST~N4*MIAMI*FL*33413~DMG*D

8*19730501*M~CLM*26407789*79.04***11:B:1*Y*A*Y*I*P~HI*BK:477

9*BF:2724*BF:2780*BF:53081~NM1*82*1*KILDARE*BEN****XX*199999

6666~PRV*PE*PXC*204C00000X~REF*G2*PBS3334~NM1*77*2*KILDARE A

SSOCIATES*****XX*1581234567~N3*2345 OCEAN BLVD~N4*MIAMI*FL*3

3111~SBR*P*01*******CI~CAS*PR*1*21.89**2*15~AMT*D*39.15~AMT*

EAF*36.89~DMG*D8*19430501*F~OI***Y*P**Y~NM1*IL*1*SMITH*JANE*

***MI*JS00111223333~N3*236 N MAIN ST~N4*MIAMI*FL*33111~NM1*P

R*2*KEY INSURANCE COMPANY*****PI*999996666~NM1*82*1~REF*G2*P

BS3334~LX*1~SV1*HC:99213*43*UN*1***1:2:3:4~DPT*472*D8*200510

03~SVD*999996666*40*HC:99213**1~CAS*CO*42*3~DTP*573*D8*20051

015~LX*2~SV1*HC:90782*15*UN*1***1:2~DTP*472*D8*20051003~SVD*

999996666*15*HC:90782**1~DTP*573*D8*20051015~LX*3~SV1*HC:J33

01*21.04*UN*1***1:2~DTP*472*D8*20051003~SVD*999996666*21.04*

HC:J3301**1~DTP*573*D8*20051015~SE*65*0024~

3.1.4 Example 4 - Medicare Secondary Payer Example(COB)

Patient and the Subscriber are the same person. The submitter is the provider. Theprovider previously sent the claim to the primary payer – Commerce. Payment receivedand the provider submitted the claim to the secondary payer, which is Medicare Part B.The claim was transmitted directly to Medicare by the submitter. Model used is providerto payer.

SUBSCRIBER/PATIENT: Wayne MedyumADDRESS: 1010 Thousand Oak Lane, Mayne, PA 17089SEX: MDOB: 1/10/1956HEALTH INSURANCE CLAIM NUMBER: 102200221B1

527MAY 2006



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Not applicable to Predetermination requests.

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delete rest of 3.1.4. Just leave placeholder sentence

DESTINATION PAYER: Medicare Part B PennsylvaniaPAYER ADDRESS: 5232 Mayne Avenue, Lyght, PA 17009

RECEIVER: Medicare Part B PennsylvaniaEDI #: 10234

BILLING PROVIDER/SENDER: SpecialistsADDRESS: 5 Map Court, Mayne, PA 17089EDI # 110101CONTACT PERSON AND PHONE NUMBER: Sue 8005558888

PATIENT ACCOUNT NUMBER: 101KEN6055CASE: Lower leg pain

SERVICES: Office Visit– POS=OfficeDATE OF SERVICE: 1/19/2005CHARGE: $120TOTAL CHARGES: $120

ELECTRONIC ROUTE: Billing provider (submitter) direct to Medicare Part B Pennsylvania


HEADER


ST*837*0002*005010X222~

1


BHT*0019*00*000001142*20050214*115101*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*SPECIALISTS*****46*1111111~

3


PER*IC*SUE*TE*8005558888~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~

5

MAY 2006528



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Line

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Line



HL BILLING PROVIDER

HL*1**20*1~

6



M1*85*2*SPECIALISTS*****XX*0100000090~

7


N3*5 MAP COURT~

8


N4*MAYNE*PA*17111~

9


REF*EI*890123456~

10

REF BILLING PROVIDER SECONDARY ID

REF*G2*110101~

11


HL*2*1*22*0~

12


SBR*S*18*MEDICARE*12****MB~

13

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*MEDYUM*WAYNE*M***MI*102200221B1~

14


N3*1010 THOUSAND OAK LANE~

15

N4 SUBSCRIBER CITY/STATE/ZIP

N4*MAYN*PA*17089~

16


DMG*D8*19560110*M~

17

529MAY 2006




2010BB PAYER

NM1 PAYER NAME

NM1*PR*2*MEDICARE PENNSYLVANIA*****PI*10234~

18

N3 PAYER ADDRESS

N3*5232 MAYNE AVENUE~

19

N4 PAYER CITY/STATE/ZIP

N4*LYGHT*PA*17009~

20

2300 CLAIM


CLM*101KEN6055*120***11:B:1*Y*A*Y*Y*B~

21

HI HEALTH CARE DIAGNOSIS CODE(S)

HI*BK:71516*BF:71906~

22

2310A REFERRING PROVIDER

NM1*DN*1*BRYHT*LEE*T~

23

REF REFERRING PROVIDER SECONDARY IDENTIFICATION

REF*1G*B01010~

24


NM1*82*1*HENZES*JACK****XX*9090909090~

25


PRV*PE*PXC*207X00000X~

26


REF*G2*110102CCC~

27



SBR*P*01**COMMERCE*****CI~

28


CAS*CO*42*25~

29


CAS*PR*2*15~

30

MAY 2006530




AMT CORRDINATION OF BENEFITS – PAYOR PAID AMOUNT

AMT*D*80~

31

AMT CORRDINATION OF BENEFITS – PATIENT RESPONSBILITY

AMT*F2*15~

32


DMG*D8*19601222*F~

33


OI***Y*B**Y~

34



NM1*IL*1*MEDYUM*CAROL****MI*COM188-404777~

35


N3*PO BOX 45~

36

N4 OTHER SUBSCIBER CITY/STATE/ZIP CODE

N4*MAYN*PA*17089~

37



NM1*PR*2*COMMERCE*****PI*59999~

38

2400 SERVICE LINE

LX*1~

39


SV1*HC:99203:25*120*UN*1***1:2~

40


DTP*472*D8*20050119~

41


SVD LINE ADJUDICATION INFORMATION

SVD*59999*80*HC:99203:25**1~

42

CAS LINE ADJUSTMENT

CAS*CO*42*25~

43

531MAY 2006




CAS LINE ADJUSTMENT

CAS*PR*2*15

44


DTP*573*D8*20050128~

45

TRAILER


SE*46*000000002~

46

Complete Data String:ST*837*0002*005010X222~BHT*0019*00*000001142*20050214*115101

*CH~NM1*41*2*SPECIALISTS*****46*1111111~PER*IC*SUE*TE*800555

8888~NM1*40*2*MEDICARE PENNSYLVANIA*****46*10234~HL*1**20*1~

NM1*85*2*SPECIALISTS*****XX*0100000009~N3*5 MAP COURT~N4*MAY

NE*PA*21236~ REF*EI*890123456~REF*G2*110101~HL*2*1*22*0~SBR*

S*18**MEDICARE*12****MB~NM1*IL*1*MEDYUM*WAYNE*M***MI*1022002

21B1~N3*1010 THOUSAND OAK LANE~N4*MAYN*PA*17089~DMG*D8*19560

110*M~NM1*PR*2*MEDICARE*****PI*10234~N3*5232 MAYNE~N4*LYGHT*

PA*17009~CLM*101KEN6055*120***11:B:1*Y*A*Y*Y*B~HI*BK:71516*B

F:71906~NM1*DN*1*BRYHT*LEE*T~REF*1G*B01010~NM1*82*1*HENZES*J

ACK****XX*9090909090~PRV*PE*PXC*207X00000X~REF*G2*110102XXX~

SBR*P*01**COMMERCE*****CI~CAS*CO*42*25~CAS*PR*2*15~AMT*D*80~

AMT*F2*15~DMG*D8*19601222*F~OI***Y*B**Y~NM1*IL*1*MEDYUM*CARO

L****MI*COM188-404777~N3*PO BOX 45~N4*MAYN*PA*17089~NM1*PR*2

*COMMERCE*****PI*59999~LX*1~SV1*HC:99203:25*120*UN*1***1:2~D

TP*472*D8*20050119~SVD*59999*80*HC:99203:25**1~CAS*CO*42*25~

CAS*PR*2*15~DTP*573*D8*20050128~SE*46*0002~

3.1.5 Example 5 - AmbulancePatient is the same person as the subscriber.The provider type is ambulance.The payeris medicare. The submitter is the same as the provider. The receiver is medicare.

SUBSCRIBER/PATIENT: Sarah JonesADDRESS: 1129 Reindeer Road, Carr, CO 80612TELEPHONE NUMBER: 305-555-1111SEX: FDOB: 07/29/1963

MAY 2006532



SUBSCRIBER ID: 012345678A

DESTINATION PAYER: Medicare Part BPAYER ADDRESS: P. O. Box 3543, Baltimore, MD. 666013543

RECEIVER: MedicareEDI #: 123245

BILLING PROVIDER/SENDER: AAA Ambulance ServiceADDRESS: 12202 Airport Way, Broomfield, CO 80221-0021TIN: 376985369NPI: 2366554859CONTACT PERSON AND PHONE NUMBER: Lisa Smith, 303-775-2536PATIENT ACCOUNT NUMBER: 05-1068

DIAGNOSIS: 8628, E8888, 9592, 8540

SERVICES: A0427 - Ambulance Transport $700.00A0425 - Mileage $8.20A0422 - Oxygen $46.00A0382 - BLS Disposable Supplies $12.30TOTAL CHARGES: $766.50

MISCELLANEOUS: Two patients were transported.

ELECTRONIC ROUTE: Billing Provider (Sender) to Medicare


HEADER


ST*837*000017712*005010X222~

1


BHT*0019*00*000017712*20050208*1112*CH~

2

1000A SUBMITTER

NM1 SUBMITTER NAME

NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~

3


PER*IC*LISA SMITH*TE*3037752536~

4

533MAY 2006



bclore

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005010X291

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Highlight


1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*MEDICARE B*****46*123245~

5



HL*1**20*1~

6



PRV*BI*PXC*3416L0300X~

7


NM1*85*2*AAA AMBULANCE SERVICE*****XX*2366554859~

8


N3*12202 AIRPORT WAY~

9


N4*BROOMFIELD*CO*800210021~

10


REF*EI*376985369~

11


HL - SUBSCRIBER

HL*2*1*22*0~

12


SBR*P*18*******MB~

13

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*JONES*SARAH*A***MI*012345678A~

14


N3*1129 REINDEER ROAD~

15

N4 SUBSCRIBER CITY, STATE, ZIP CODE

N4*CARR*CO*80612~

16

MAY 2006534





DMG*D8*19630729*F~

17

2010BB PAYER

NM1 PAYER NAME

NM1*PR*2*MEDICARE PART B*****PI*123245~

18

N3 PAYER ADDRESS

N3*PO BOX 3543~

19

N4 LOCATION

N4*BALTIMORE*MD*666013543~

20

2300 CLAIM


CLM*051068*766.50***41::1*Y*A*Y*Y*P*OA~

21

DTP DATE ACCIDENT

DTP*439*D8*20050208~

22

CR1 AMBULANCE TRANSPORT INFORMATION

CR1*LB*275**A*DH*21****PATIENT IMOBILIZED~

23

CRC AMBULANCE CERTIFICATION

CRC*07*Y*04*06*09~

24

CRC AMBULANCE CERTIFICATION

CRC*07*N*05*07*08~

25

HI - HEALTH CARE DIAGNOSIS

HI*BK:8628*BF:E8888*BF:9592*BF:8540~

26

2310E AMBULANCES PICK-UP LOCATION

NM1 PICK UP LOCATION

NM1*PW*2*~

27

N3 PICK UP ADDRESS

N3*1129 REINDEER ROAD~

28

N4 PICK UP LOCATION

N4*CARR*CO*80612~

29

535MAY 2006



bclore

Callout

CLM*051068*766.50***41::1*Y*A*Y*Y*P*OA********08~

bclore

Highlight


2310F AMBULANCE DROP-OFF LOCATION

NM1 DROP OFF LOCATION

NM1*45*2~

30

N3 - DROP OFF ADDRESS

N3*10005 BANNOCK ST~

31

N4 - DROP OFF LOCATION

N4*CHEYENNE*WY*82009~

32

2400 SERVICE LINE


LX*1~

33

SV1 - PROFESSIONAL SERVICE

SV1*HC:A0427:RH*700*UN*1***1:2:3:4**Y~

34


DTP*472*D8*20050208~

35

QTY - AMBULANCE PATIENT COUNT

QTY*PT*2~

36

REF - LINE ITEM CONTROL NUMBER

REF*6R*1001~

37

NTE - LINE NOTE

NTE*ADD*CARDIAC EMERGENCY~

38


LX*2~

39


SV1*HC:A0425:RH*8.20*UN*21***1:2:3:4**Y~

40

DTP - SERVICE DATE

DTP*472*D8*20050208~

41

QTY - AMBULANCE PATIENT COUNT

QTY*PT*2~

42

MAY 2006536



bclore

Cross-Out

bclore

Cross-Out


REF - LINE CONTROL NUMBER

REF*6R*1002~

43

LX - SERVICE LINE NUMBER

LX*3~

44


SV1*HC:A0422:RH*46*UN*1***1:2:3:4**Y~

45

DTP - SERVICE DATE

DTP*472*D8*20050208~

46


REF*6R*1003~

47

LX - SERVICE LINE NUMBER

LX*4~

48


SV1*HC:A0382:RH*12.30*UN*1***1:2:3:4**Y~

49

DTP - SERVICE DATE

DTP*472*D8*20050208~

50


REF*6R*1004~

51

TRAILER


SE*52*000017712~

52

Complete Data String:ST*837*000017712*005010X222~BHT*0019*00*000017712*20050208*1

112*CH~NM1*41*2*AAA AMBULANCE SERVICE*****46*376985369~PER*I

C*LISA SMITH*TE*3037752536~NM1*40*2*MEDICARE B*****46*123245

~HL*1**20*1~PRV*BI*PXC*3416L0300X~NM1*85*2*AAA AMBULANCE SER

VICE*****XX*2366554859~N3*12202 AIRPORT WAY~N4*BROOMFIELD*CO

*800210021~REF*EI*376985369~HL*2*1*22*0~SBR*P*18*******MB~NM

1*IL*1*JONES*SARAH*A***MI*012345678A~N3*1129 REINDEER ROAD~N

4*CARR*CO*80612~DMG*D8*19630729*F~NM1*PR*2*MEDICARE PART B**

***PI*123245~N3*PO BOX 3543~N4*BALTIMORE*MD*666013543~CLM*05

537MAY 2006



bclore

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Cross-Out

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Callout

48

bclore

Highlight

bclore

Highlight

bclore

Callout

005010X291

bclore

Callout

CLM*051068*766.50***41::1*Y*A*Y*Y*P*OA********08~

1068*766.50***41::1*Y*A*Y*Y*P*OA~DTP*439*D8*20050208~CR1*LB*

275**A*DH*21****PATIENT IMOBILIZED~CRC*07*Y*04*06*09~CRC*07*

N*05*07*08~HI*BK:8628*BF:E8888*BF:9592*BF:8540~NM1*PW*2*~N3*

1129 REINDEER ROAD~N4*CARR*CO*80612~NM1*45*2~N3*10005 BANNOC

K ST~N4*CHEYENNE*WY*82009~LX*1~SV1*HC:A0427:RH*700*UN*1***1:

2:3:4**Y~DTP*472*D8*20050208~QTY*PT*2~REF*6R*1001~NTE*ADD*CA

RDIAC EMERGENCY~LX*2~SV1*HC:A0425:RH*8.20*UN*21***1:2:3:4**Y

~DTP*472*D8*20050208~QTY*PT*2~REF*6R*1002~LX*3~SV1*HC:A0422:

RH*46*UN*1***1:2:3:4**Y~DTP*472*D8*20050208~REF*6R*1003~LX*4

~SV1*HC:A0382:RH*12.30*UN*1***1:2:3:4**Y~DTP*472*D8*20050208

~REF*6R*1004~SE*52*000017712~

3.1.6 Example 6 - Chiropractic ExamplePatient is the same person as the Subscriber. Payer is Medicare Part B. The claim issubmitter directly to Medicare, the submitter being the provider.

SUBSCRIBER/PATIENT: Matthew J WilliamsonADDRESS: 128 Broadcreek, Baltimore, MD 21234SEX: MDOB: 1/10/1925PAYER ID NUMBER: SSNSSN: 123456789A

DESTINATION PAYER: Medicare Part B MarylandPAYER ADDRESS: 1946 Greenspring Drive, Timonium, MD 21093

RECEIVER: Medicare Part B MarylandEDI #: 12345

BILLING PROVIDER/SENDER: David M Greene, DCADDRESS: 1264 Oakwood Ave, Baltimore, MD 21236EDI#: S01057CONTACT PERSON AND PHONE NUMBER: Kathi Wilmoth 4105558888

PATIENT ACCOUNT NUMBER: 125WILLCASE: Acute Back Pain

SERVICES: Chiropractic Manipulative Treatment - POS=OfficeDATE OF SERVICE: 2/15/2005CHARGE: $145.50

MAY 2006538



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Initial Treatment Date: 01/15/20050Acute Manifestation Date: 01/10/2005Last X-Ray Date: 01/13/2005TOTAL CHARGES: $145.50

ELECTRONIC ROUTE: Billing provider (sender) direct to Maryland Medicare Part B


HEADER


ST*837*3701*005010X222~

1


BHT*0019*00*007227*20050215*075420*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*DAVID GREEN*****46*S01057~

3


PER*IC*KATHY SMITH*TE*4105558888~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~

5



HL*1**20*1~

6



NM1*85*1*GREENE*DAVID*M***XX*1234567890~

7


N3*1264 OAKWOOD AVE~

8



9

REF BILLING PROVIDER SECONDARY ID

REF*EI*987654321~

10

539MAY 2006



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2005

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005010X291

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PER*IC*DR*TE*4105551212~

11


HL*2*1*22*0~

12


SBR*P*18*******MB~

13

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*WILLIAMSON*MATTHEW*J***MI*123456789A~

14


N3*128 BROADCREEK~

15

N4 SUBSCRIBER CITY


16


DMG*D8*19250110*M~

17

2010BB SUBSCRIBER / PAYER

NM1 PAYER NAME

NM1*PR*2*MEDICARE PART B MARYLAND*****PI*C12345~

18

2300 CLAIM


CLM*125WILL*145.5***11>B>1*Y*A*Y*Y~

19

DTP - INITIAL TREATMENT DATE

DTP*454*D8*20050115~

20

DTP - ACUTE MANIFESTATION DATE

DTP*453*D8*20050110~

21

DTP - LAST X-RAY DATE

DTP*455*D8*20050113~

22

CR2 SPINAL MANIPULATION SERVICE INFORMATION

CR2********A**CHRONIC PAIN AND DISCOMFORT~

23

MAY 2006540




HI HEALTH CARE DIAGNOSIS CODE(S)

HI*BK>7215~

24

2400 SERVICE LINE


LX*1~

25


SV1*HC>98940*145.5*UN*1***1~

26

DTP - SERVICE DATE(S)

DTP*472*D8*20050215~

27

LINE ITEM CONTROL NUMBER

REF*6R*01~

28

TRAILER


SE*29*3701~

29


~NM1*41*2*DAVID GREEN*****46*S01057~PER*IC*KATHY SMITH*TE*41

05558888~NM1*40*2*MEDICARE PART B MARYLAND*****46*12345~HL*1

**20*1~NM1*85*1*GREENE*DAVID*M***XX*1234567890~N3*1264 OAKWO

OD AVE~N4*BALTIMORE*MD*21236~REF*EI*987654321~PER*IC*DR*TE*4

105551212~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*WILLIAMSON*

MATTHEW*J***MI*123456789A~N3*128 BROADCREEK~N4*BALTIMORE*MD*

21234~DMG*D8*19250110*M~NM1*PR*2*MEDICARE PART B MARYLAND***

**PI*C12345~CLM*125WILL*145.5***11>B>1*Y*A*Y*Y~DTP*454*D8*20

050115~DTP*453*D8*20050110~DTP*455*D8*20050113~CR2********A*

*CHRONIC PAIN AND DISCOMFORT~HI*BK>7215~LX*1~SV1*HC>98940*14

5.5*UN*1***1~DTP*472*D8*20050215~REF*6R*01~SE*31*3701~

3.1.7 Example 7 - OxygenPatient is the same person as the Subscriber. Claim is submitted by provider directlyand the Payer is Medicare DMERC.

SUBSCRIBER/PATIENT: Terry Smith

541MAY 2006



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005010X291

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ADDRESS: 121 South Street, Richmond, IN 46236SEX: FDOB: 01/05/38HIC#: 111-22-2333A

DESTINATION PAYER: DMERC CarrierPAYOR ADDRESS: 926 W Angel Rd, Richmond, IN 46236EDI #: 99999

BILLING PROVIDER/SENDER: Oxygen Supply CompanyADDRESS: 1800 East Ridge Drive, Richmond, IN 46224TIN: 389999999EDI #: ABC11111NPI#: 9992233334DMERC Provider #: 099999999CONTACT PERSON AND PHONE NUMBER: Bonnie, 812-555-1111EMAIL: [email protected]

ORDERING PROVIDER: Dr. Larry WilsonADDRESS: 1212 North Meridian, Richmond, IN 46223NPI#: 5555511111UPIN#: X99999PHONE NUMBER: 555-444-6666

PATIENT ACCOUNT NUMBER: R03996273 #01CASE: Chronic Airway Obstruction

SERVICE: DOS=03/21/05 POS=HomeSERVICES: Oxygen concentrator and Portable gaseous O2CHARGES: Oxygen concentrator = $461.10, Portable gaseous oxygen = $59.14

TOTAL CHARGES: $520.24


HEADER


ST*837*0001*005010X222~

1


BHT*0019*00*16*20050326*1036*CH~

2

MAY 2006542



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005010X291

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1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~

3


PER*IC*BONNIE*TE*8125551111*EM*[email protected]~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*DMERC CARRIER*****46*99999~

5


HL BILLING PROVIDER

HL*1**20*1~

6



NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*9992233334~

7


N3*1800 EAST RIDGE DRIVE~

8


N4*RICHMOND*IN*46224~

9

REF BILLING PROIVDER TAX IDENTIFIER

REF*EI*389999999~

10


HL SUBSCRIBER

HL*2*1*22*0~

11


SBR*P*18*******MB~

12

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*TERRY****MI*111222333A~

13


N3*121 SOUTH ST~

14

543MAY 2006




N4 SUBSCRIBER CITY


15


DMG*D8*19380105*F~

16


NM1 PAYER NAME

NM1*PR*2*DMERC CARRIER*****PI*99999~

17

2300 CLAIM


CLM*R03996273 #01*520.24***11:B:1*Y*A*Y*Y~

18


HI*BK:496*BF:51881*BF:2859~

19

2400 SERVICE LINE


LX*1~

20


SV1*HC:E1390:RR*461.1*UN*1***1:2~

21

PWK DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR

PWK*CT*AD~

22

CR3 DURABLE MEDICAL EQUIPMENT CERTIFICATION

CR3*R*MO*99~

23

DTP SERVICE DATE

DTP*472*RD8*20050321-20050321~

24

DTP CERTIFICATION REVISION/RECERTIFICATION DATE

DTP*607*D8*20050321~

25

DTP BEGIN THERAPY DATE

DTP*463*D8*20040321~

26

DTP LAST CERTIFICATION DATE

DTP*461*D8*20050321~

27

MAY 2006544



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CLM*R03996273 #01*520.24***11:B:1*Y*A*Y*Y**********08~

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2420E ORDERING PROVIDER

NM1 ORDERING PROVIDER NAME

NM1*DK*1*WILSON*LARRY****XX*5555511111~

28

N3 ORDERING PROVIDER ADDRESS

N3*1212 NORTH MERIDIAN~

29

N4 ORDERING PROVIDER CITY/STATE/ZIP CODE


30

REF ORDERING PROVIDER INFORMATION

REF*1G*X99999~

31

PER ORDERING PROVIDER CONTACT INFORMATION

PER*IC*LEE*TE*5554446666~

32

2440 FORM IDENTIFICATION CODE

LQ FORM IDENTIFICATION CODE

LQ*UT*04.03~

33

FRM SUPPORTING DOCUMENTATION

FRM*1A**056~

34


FRM*1C**20050228~

35


FRM*2**1~

36


FRM*3**1~

37


FRM*4*Y~

38


FRM*5**2~

39


FRM*7*Y~

40

545MAY 2006





FRM*8*N~

41


FRM*9*Y~

42

2400 SERVICE LINE


LX*2~

43


SV1*HC:E0431:RR*59.14*UN*1***1:2~

44

PWK DURABLE MEDICAL EQUIPMENT CERTIFICATE OF MEDICAL NECESSITY INDICATOR

PWK*CT*AD~

45

DTP SERVICE DATE

DTP*472*RD8*20050321-20050321~

46


CR3*R*MO*99~

47

DTP CERTIFICATION REVISION/RECERTIFICATION DATE

DTP*607*D8*20050321~

48


DTP*463*D8*20040321~

49


DTP*461*D8*20050321~

50



NM1*DK*1*WILSON*LARRY****XX*5555511111~

51


N3*1212 NORTH MERIDIAN~

52



53

MAY 2006546



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REF*1G*X99999~

54



55



LQ*UT*04.03~

56


FRM*1A**056~

57


FRM*1C**20050228~

58


FRM*2**1~

59


FRM*3**1~

60


FRM*4*Y~

61


FRM*5**2~

62


FRM*7*Y~

63


FRM*8*N~

64


FRM*9*Y~

65

TRAILER


SE*66*0001~

66

547MAY 2006



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Complete Data String:ST*837*0001*005010X222~BHT*0019*00*16*20050326*1036*CH~NM1*4

1*2*OXYGEN SUPPLY COMPANY*****46*ABC11111~PER*IC*BONNIE*TE*8

125551111*EM*[email protected]~NM1*40*2*DMERC CARRIER*****

46*99999~HL*1**20*1~NM1*85*2*OXYGEN SUPPLY COMPANY*****XX*99

92233334~N3*1800 EAST RIDGE DRIVE~N4*RICHMOND*IN*46224~REF*E

I*389999999~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1*SMITH*TER

RY****MI*111222333A~N3*121 SOUTH ST~N4*RICHMOND*IN*46236~DMG

*D8*19380105*F~NM1*PR*2*DMERC CARRIER*****PI*99999~CLM*R0399

6273 #01*520.24***11:B:1*Y*A*Y*Y~HI*BK:496*BF:51881*BF:2859~

LX*1~SV1*HC:E1390:RR*461.1*UN*1***1:2~PWK*CT*AD~CR3*R*MO*99~

DTP*472*RD8*20050321-20050321~DTP*607*D8*20050321~DTP*463*D8

*20040321~DTP*461*D8*20050301~NM1*DK*1*WILSON*LARRY****XX*55

55511111~N3*1212 NORTH MERIDIAN~N4*RICHMOND*IN*46223~REF*1G*

X99999~PER*IC*LEE*TE*5554446666~LQ*UT*04.03~FRM*1A**056~FRM*

1C**20050228~FRM*2**1~FRM*3**1~FRM*4*Y~FRM*5**2~FRM*7*Y~FRM*

8*N~FRM*9*Y~LX*2~SV1*HC:E0431:RR*59.14*UN*1***1:2~PWK*CT*AD~

CR3*R*MO*99~DTP*472*RD8*20050321-20050321~DTP*607*D8*2005032

1~DTP*463*D8*20040321~DTP*461*D8*20050301~NM1*DK*1*WILSON*LA

RRY****XX*5555511111~N3*1212 NORTH MERIDIAN~N4*RICHMOND*IN*4

6223~REF*1G*X99999~PER*IC*LEE*TE*5554446666~LQ*UT*04.03~FRM*

1A**056~FRM*1C**20050228~FRM*2**1~FRM*3**1~FRM*4*Y~FRM*5**2~

FRM*7*Y~FRM*8*N~FRM*9*Y~SE*66*0001~

MAY 2006548



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CLM*R03996273 #01*520.24***11:B:1*Y*A*Y*Y**********08~

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005010X291

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CERTIFICATE OF MEDICAL NECESSITYCMS-484 — OXYGEN

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

Form ApprovedOMB No. 0938-0534

Form CMS-484 (09/05)

SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___

SECTION B Information in This Section May Not Be Completed by the Supplier of the Items/Supplies.

PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN _______________________

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or applicableNPI NUMBER/LEGACY NUMBER

(__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________

NAME and ADDRESS of FACILITYif applicable (see reverse)

PHYSICIAN NAME, ADDRESS, TELEPHONE and applicable NPI NUMBER or UPIN

(__ __ __) __ __ __ - __ __ __ __ UPIN or NPI #_________________

PLACE OF SERVICE______________ HCPCS CODE PT DOB ____/____/____ Sex ____ (M/F)

EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) DIAGNOSIS CODES (ICD-9): ______ ______ ______ ______

ANSWERS ANSWER QUESTIONS 1-9. (Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)

ANSWER QUESTIONS 7-9 ONLY IF PO2 = 56–59 OR OXYGEN SATURATION = 89 IN QUESTION 1

NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):NAME: ____________________________________________TITLE: ________________________EMPLOYER:__________________________

(1) Narrative description of all items, accessories and options ordered; (2) Supplier’s charge and (3) Medicare Fee Schedule Allowance for eachitem, accessory and option. (See instructions on back.)

I certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of MedicalNecessity (including charges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that section may subject me to civil or criminal liability.

PHYSICIAN’S SIGNATURE ______________________________________________________________________ DATE _____/_____/_____

________________________________________

a)_________mm Hgb)_____________%c)____/____/____

1 2 3

1 2 3

Y N D

______________LPM

a)_________mm Hgb)_____________%c)____/____/____

1. Enter the result of most recent test taken on or before the certification date listed in Section A. Enter (a) arterial blood gas PO2 and/or (b) oxygen saturation test; (c) date of test.

2. Was the test in Question 1 performed (1) with the patient in a chronic stable state as an outpatient, (2) within two days prior to discharge from an inpatient facility to home, or (3) under other circumstances?

3. Circle the one number for the condition of the test in Question 1: (1) At Rest; (2) During Exercise; (3) During Sleep

4. If you are ordering portable oxygen, is the patient mobile within the home? If you are not ordering portable oxygen, circle D.

5. Enter the highest oxygen flow rate ordered for this patient in liters per minute. If less than 1 LPM, enter a “X”.

6. If greater than 4 LPM is prescribed, enter results of most recent test taken on 4 LPM. This may be an (a) arterial blood gas PO2 and/or (b) oxygen saturation test with patient in a chronic stable state. Enter date of test (c).

Y N

Y N

Y N

7. Does the patient have dependent edema due to congestive heart failure?

8. Does the patient have cor pulmonale or pulmonary hypertension documented by P pulmonale on an EKG or by an echocardiogram, gated blood pool scan or direct pulmonary artery pressure measurement?

9. Does the patient have a hematocrit greater than 56%?

SECTION C Narrative Description of Equipment and Cost

SECTION D Physician Attestation and Signature/Date

DME MAC 484.03

MS31402

1

MS31402

1

MS31402

1

MS31402

1

MS31402

1

MS31402

1

3.1.8 Example 8 - WheelchairPatient is the same person as the Subscriber. Claim is submitted by provider directlyand the Payer is Medicare DMERC.

SUBSCRIBER/PATIENT: James SmithADDRESS: 12 Main Street, Frankfort, IN 46209SEX: MDOB: 10/23/1920HIC#: 987-65-4321A

DESTINATION PAYER: DMERC CarrierPAYOR ADDRESS: 926 W Angel Rd, Richmond, IN 46236EDI #: 99999

BILLING PROVIDER/SENDER: XYZ Wheelchairs IncADDRESS: 1440 North Street, Lafayette, IN 47904TIN: 123567989EDI #: ABC55NPI#: 7778889999DMERC Provider #: 0426960001CONTACT PERSON AND PHONE NUMBER: Jane Doe, 222-555-1111EMAIL: [email protected]

ORDERING PROVIDER: Dr. Randall WilsonADDRESS: 1226 West Railroad St, Lafayette, IN 47905NPI#: 1111155555UPIN#: M12345CONTACT PERSON AND PHONE NUMBER: Lee, 765-297-7999

PATIENT ACCOUNT NUMBER: SMI123CASE: Paralysis & CVA

SERVICE: DOS=03/21/05 POS=HomeSERVICES: Standard wheelchair rental for $75.00


HEADER


ST*837*112233*005010X222~

1

MAY 2006550



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005010X291



BHT*0019*00*16*20050326*1036*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~

3


PER*IC*JANE*TE*2225551111~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*DMERC CARRIER*****46*99999~

5



HL*1**20*1~

6



NM1*85*2*XYZ WHEELCHAIR INC*****XX*7778889999~

7


N3*1440 NORTH STREET~

8


N4*LAFAYETTE*IN*47904~

9

REF BILLING PROVIDER TAX IDENTIFIER

REF*EI*123567989~

10

REF BILLING PROIVDER SECONDARY IDENTIFIER

REF*G2*0426960001~

11


HL - SUBSCRIBER

HL*2*1*22*0~

12


SBR*P*18*******MB~

13

551MAY 2006





PAT*******01*155~

14

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*JAMES****MI*987654321A~

15


N3*12 MAIN ST~

16

N4 SUBSCRIBER CITY

N4*FRANKFORT*IN*46209~

17


DMG*D8*19201023*M~

18


NM1 PAYER NAME

NM1*PR*2*DMERC CARRIER*****PI*99999~

19

2300 CLAIM


CLM*SMI123*75***12:B:1*Y*A*Y*Y~

20


HI*BK:436*BF:3449~

21

2400 SERVICE LINE


LX*1~

22


SV1*HC:K0001:RR:KH:BR*75*UN*1***1:2~

23

PWK CLAIM SUPPLEMENTAL INFORMATION

PWK*CT*AD~

24


CR3*I*MO*99~

25

MAY 2006552



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CLM*SMI123*75***12:B:1*Y*A*Y*Y**********08~

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DTP SERVICE DATE

DTP*472*RD8*20050321-20050321~

26


DTP*463*D8*20040321~

27


DTP*461*D8*20050321~

28

MEA TEST RESULT

MEA*TR*HT*70~

29



NM1*DK*1*WILSON*RANDALL****XX*1111155555~

30


N3*1226 WEST RAILROAD STREET~

31


N4*LAFAYETTE*IN*47905~

32


REF*1G*M12345~

33



34



LQ*UT*02.03B~

35


FRM*1*Y~

36


FRM*2*N~

37


FRM*3*N~

38

553MAY 2006



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FRM*4*N~

39


FRM*5**8~

40


FRM*8*N~

41


FRM*9*Y~

42

TRAILER


SE*43*112233~

43


*41*2*XYZ WHEELCHAIRS INC*****46*ABC55~PER*IC*JANE*TE*222555

1111~NM1*40*2*DMERC CARRIER*****46*99999~HL*1**20*1~NM1*85*2

*XYZ WHEELCHAIR INC*****XX*7778889999~N3*1440 NORTH STREET~N

4*LAFAYETTE*IN*47904~REF*EI*123567989~REF*G2*0426960001~HL*2

*1*22*0~SBR*P*18*******MB~PAT*******01*155~NM1*IL*1*SMITH*JA

MES****MI*987654321A~N3*12 MAIN ST~N4*FRANKFORT*IN*46209~DMG

*D8*19201023*M~NM1*PR*2*DMERC CARRIER*****PI*99999~CLM*SMI12

3*75***12:B:1*Y*A*Y*Y~HI*BK:436*BF:3449~LX*1~SV1*HC:K0001:RR

:KH:BR*75*UN*1***1:2~PWK*CT*AD~CR3*I*MO*99~DTP*472*RD8*20050

321-20050321~DTP*463*D8*20040321~DTP*461*D8*20050321~MEA*TR*

HT*70~NM1*DK*1*WILSON*RANDALL****XX*1111155555~N3*1226 WEST

RAILROAD STREET~N4*LAFAYETTE*IN*47905~REF*1G*M12345~PER*IC*L

EE*TE*7659259999~LQ*UT*02.03B~FRM*1*Y~FRM*2*N~FRM*3*N~FRM*4*

N~FRM*5**8~FRM*8*N~FRM*9*Y~SE*43*112233~

MAY 2006554



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CLM*SMI123*75***12:B:1*Y*A*Y*Y**********08~

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41

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005010X291

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U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES FORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0679

CERTIFICATE OF MEDICAL NECESSITY DMERC 02.03BMANUAL WHEELCHAIRS

SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER

(__ __ __) __ __ __ - __ __ __ __ HICN ____________________________

SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER

(__ __ __) __ __ __ - __ __ __ __ NSC # __________________________________

PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)

NAME and ADDRESS of FACILITY if applicable (See PHYSICIAN NAME, ADDRESS, TELEPHONE and UPIN NUMBER

HCPCS CODES:

SECTION B Information in This Section May Not Be Completed by the Supplier of the Items/Supplies.

EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) DIAGNOSIS CODES (ICD-9): _________ _________ _________ _________

ITEM ADDRESSED ANSWERS ANSWER QUESTIONS 1, 5, 8 AND 9 FOR MANUAL WHEELCHAIR BASE, 1-5 FOR WHEELCHAIROPTIONS/ACCESSORIES.(Circle Y for Yes, N for No, or D for Does Not Apply, unless otherwise noted.)

Manual Whlchr Base AndAll Accessories

Y N D 1. Does the patient require and use a wheelchair to move around in their residence?

Reclining Back Y N D 2. Does the patient have quadriplegia, a fixed hip angle, a trunk cast or brace, excessive extensortone of the trunk muscles or a need to rest in a recumbent position two or more times during theday?

Elevating Legrest Y N D 3. Does the patient have a cast, brace or musculoskeletal condition, which prevents 90 degree flexionof the knee, or does the patient have significant edema of the lower extremities that requires anelevating legrest, or is a reclining back ordered?

Adjustable Height Armrest Y N D 4. Does the patient have a need for arm height different than that available using non-adjustablearms?

Reclining Back;Adjustable Ht. Armrest;Any Type Ltwt. Whlchr

5. How many hours per day does the patient usually spend in the wheelchair? (1–24) (Round up tothe next hour)

Any Type Ltwt. Whlchr Y N D 8. Is the patient able to adequately self-propel (without being pushed) in a standard weight manualwheelchair?

Any Type Ltwt. Whlchr Y N D 9. If the answer to question #8 is "No," would the patient be able to adequately self-propel (withoutbeing pushed) in the wheelchair which has been ordered?

NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):NAME: ____________________________________________ TITLE: EMPLOYER:

SECTION C Narrative Description of Equipment and Cost(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule

Allowance for each item, accessory, and option. (See instructions on back.) If additional space is needed, list wheelchair baseand most costly options/accessories on this page and continue on Form CMS-854.

rr CHECK HERE IF ADDITIONAL OPTIONS/ACCESSORIES ARE LISTED ON Form CMS-854

SECTION D Physician Attestation and Signature/DateI certify that I am the treating physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (includingcharges for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity informationin Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in thatsection may subject me to civil or criminal liability.

PHYSICIAN'S SIGNATURE ________________________________ DATE / / (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)

CMS-844 (05/97)

Reverse)

PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.) PLACE OF SERVICE

(__ __ __) __ __ __ - __ __ __ __ UPIN # __________________________________

Common Work Station

MS31402

Y

MS31402

Y

MS31402

Y

MS31402

Y

MS31402

Y

MS31402

Y

3.1.9 Example 9 - AnesthesiaPatient is the same as the subscriber. Payer is Medicare. Encounter is billed directly toMedicare.

SUBSCRIBER/PATIENT: Margaret JonesADDRESS: 123 Rainbow Road, Nashville, TN 37232TELEPHONE: 615-555-1212SEX: FDOB: 03/03/1974EMPLOYER: ACME Inc.SUBSCRIBER #: 123456789A

SECONDARY COVERAGE

DESTINATION PAYER: ABC PayerPAYER ADDRESS: P.O. Box 1465, Nashville, TN, 37232PAYER ORGANIZATION ID: 05440

RECEIVER: ABC PayerEDI #: 05440

BILLING PROVIDER/SENDER: Provider Medical GroupADDRESS: 1234 West End Ave, Nashville, TN, 37232NPI#: 2366554859TIN: 756473826EDI #: N305CONTACT PERSON AND PHONE NUMBER: Nina, 615-555-1212 ext.911

RENDERING PROVIDER: Dr. Jacob E. Townsend/AnesthesiologistNPI: 5678912345MEDICARE PROVIDER ID#: 9741234PLACE OF SERVICE: Provider OP HospitalPLACE OF SERVICE ADDRESS: 345 Main Drive, Nashville, TN,37232PLACE OF SERVICE ID#: 43294867

PATIENT ACCOUNT NUMBER: 543211230CASE: Laser Eye Surgery.

VISIT: DOS=1/12/2005 POS=Outpatient HospitalSERVICES: Anesthesia for the Laser Eye SurgeryCHARGES: Anesthesia, 61 minutes = $827.00

MAY 2006556



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Predetermination request is a direct submission.

CONCURRENCY: 2 casesPHYSICAL STATUS: NormalPATIENT CONTROL #: 153829140MEDICAL RECORD ID #: 006653794

TOTAL CHARGES: $827.00

ELECTRONIC ROUTE: Billing Provider (sender) to ABC PAYER direct


HEADER


ST*837*0001*005010X222~

1

BHT BEGINNING OF HIERARCHICAL

BHT*0019*00*0123*20050117*1023*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*PROVIDER MEDICAL GROUP*****46*N305~

3


PER*IC*NINA*TE*6155551212*EX*911~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*ABC PAYER*****46*05440~

5



HL*1**20*1~

6



NM1*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~

7


N3*1234 WEST END AVE~

8



9

557MAY 2006



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REF BILLING PROVIDER TAX IDENTIFICATION

REF*EI*756473826~

10


HL - SUBSCRIBER

HL*2*1*22*0~

11


SBR*P*18*******MB~

12

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*JONES*MARGARET****MI*123456789A~

13

N3 SUBSCRIBER STREET ADDRESS

N3*123 RAINBOW ROAD~

14

N4 SUBSCRIBER CITY/STATE/ZIP


15


DMG*D8*19740303*F~

16


NM1 PAYER NAME

NM1*PR*2*ABC PAYER*****PI*05440~

17

2300 CLAIM


CLM*153829140*827***22>B>1*Y*A*Y*Y~

18


HI*BK>36616~

19



NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~

20

PRV RENDERING PROVIDER TAXONOMY INFORMATION

PRV*PE*ZZ*207L00000X~

21

MAY 2006558



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CLM*153829140*827***22>B>1*Y*A*Y*Y**********08~

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REF*G2*9741234~

22

2310C SERVICE FACILITY LOCATION


NM1*77*2*PROVIDER OP HOSP*****XX*432198765~

23

N3 SERVICE FACILITY LOCATION

N3*345 MAIN DRIVE~

24

N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP


25

2400 SERVICE LINE

LX SERVICE LINE COUNT

LX*1~

26


SV1*HC>00142>QK>QS>P1*827*MJ*61***1~

27


DTP*472*D8*20050112~

28

TRAILER


SE*29*0001~

29


*41*2*PROVIDER MEDICAL GROUP*****46*N305~PER*IC*NINA*TE*6155

551212*EX*911~NM1*40*2*ABC PAYER*****46*05440~HL*1**20*1~NM1

*85*2*PROVIDER MEDICAL GROUP*****XX*2366554859~N3*1234 WEST

END AVE~N4*NASHVILLE*TN*37232~REF*EI*756473826~HL*2*1*22*0~S

BR*P*18*******MB~NM1*IL*1*JONES*MARGARET****MI*123456789A~N3

*123 RAINBOW ROAD~N4*NASHVILLE*TN*37232~DMG*D8*19740303*F~NM

1*PR*2*ABC PAYER*****PI*05440~CLM*153829140*827***22>B>1*Y*A

*Y*Y~HI*BK>36616~NM1*82*1*TOWNSEND*JACOB*E***XX*5678912345~P

RV*PE*ZZ*207L00000X~REF*1G*A41234~NM1*77*2*PROVIDER OP HOSP*

****XX*432198765~N3*345 MAIN DRIVE~N4*NASHVILLE*TN*37232~LX*

1~SV1*HC>00142>QK>QS>P1*827*MJ*61***1~DTP*472*D8*20050112~SE

559MAY 2006



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CLM*153829140*827***22>B>1*Y*A*Y*Y**********08

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27

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005010X291

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*29*0001~

3.1.10 Example 10 - Drug examplesThe examples in this section have been created with a mixture of uppercase andlowercase letters. This demonstrates that this is an acceptable representation.

3.1.10.1 Drug Example 1 - Drug administered in the PhysicianOffice

Example of service in a physician office, which includes the billing for a drug administeredin the office.

SUBSCRIBER/PATIENT: Steve R. VaughnADDRESS: 236 Diamond St., Las Vegas, NV 89109SEX: MDOB: 5/1/1943SUBSCRIBER IDENTIFICATION #: MBRID12345GROUP #: GRP01020102

DESTINATION RECEIVER: XYZ ReceiverETIN: 369852758

DESTINATION PAYER: R&R Health PlanNATIONAL PLAN IDENTIFIER: PLANID12345

BILLING PROVIDER/SENDER: Associates in MedicineADDRESS: 1313 Las Vegas Blvd., Las Vegas, NV 89109TIN: 587654321NATIONAL PROVIDER IDENTIFIER: 1234567893CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801)726-8899

PAY-TO PROVIDER: Associates in Medicine

RENDERING PROVIDER: Jim HendrixNATIONAL PROVIDER IDENTIFIER: 1122333341TAXONOMY IDENTIFIER: 208D00000X

PATIENT ACCOUNT NUMBER: CLMNO12345

DIAGNOSIS: 0359.1

MAY 2006560



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27

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CASE: The service provided on 7/11/2004 is that the patient received an injection ofimmune globulin during an office visit. The service is billed with procedure code 90782.

Coding for the drug is accomplished with a HCPCS procedure code of J1550 (injection,gammablobulin, intramuscular, 10 cc). And, the drug is also coded with NDC of00026-0635-12 (BayGam® SDV, PF 10 ML).

Place of service is an office. Total billed charges are $103.37. Sales tax is $3.37.

The primary purpose of this example is to demonstrate how drugs are billed along withservices when provided by a physician office. Billing for the drug is found in segments#25-30 below.


HEADER


ST*837*0711*005010X222~

1


BHT*0019*00*0013*20040801*1200*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*Associates in Medicine*****46*587654321~

3


PER*IC*Bud Holly*TE*8017268899~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*XYZ Receiver*****46*369852758~

5



HL*1**20*1~

6



NM1*85*2*Associates in Medicine*****XX*587654321~

7


N3*1313 Las Vegas Boulevard~

8

561MAY 2006



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for which the predetermination is requested

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005010X291

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N4*Las Vegas*NV*89109~

9


REF*EI*587654321~

10


HL - SUBSCRIBER

HL*2*1*22*0~

11


SBR*P*18*GRP01020102******CI~

12

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*Vaughn*Steve*R***MI*MBRID12345~

13


N3*236 Diamond ST~

14

N4 SUBSCRIBER CITY

N4*Las Vegas*NV*89109~

15


DMG*D8*19430501*M~

16


NM1 PAYER NAME

NM1*PR*2*R&R Health Plan*****XY*PLANID12345~

17

2300 CLAIM


CLM*CLMNO12345*103.37***11:B:1*Y*A*Y*Y~

18

HI HEALTH CARE DIAGNOSIS CODE

HI*BK:03591~

19



NM1*82*1*Hendrix*Jim****XX*1122333341~

20

MAY 2006562



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CLM*CLMNO12345*103.37***11:B:1*Y*A*Y*Y**********08~

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PRV*PE*PXC*208D00000X~

21

2400 SERVICE LINE


LX*1~

22


SV1*HC:90782*50*UN*1*11**1~

23


DTP*472*D8*20040711~

24

2400 SERVICE LINE

LX*2~

25


SV1*HC:J1550*53.37*UN*1*11**1~

26


DTP*472*D8*20040711~

27

AMT SALE TAX AMOUNT

AMT*T*3.37~

28

2410 DRUG IDENTIFICATION

LIN DRUG IDENTIFICATION

LIN**N4*00026063512~

29

CTP DRUG QUANTITY

CTP****10*ML~

30

TRAILER


SE*31*0711~

31


*41*2*Associates in Medicine*****46*587654321~PER*IC*Bud Hol

ly*TE*8017268899~NM1*40*2*XYZ Receiver*****46*369852758~HL*1

**20*1~NM1*85*2*Associates in Medicine*****XX*1234567893~N3*

563MAY 2006



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1313 Las Vegas Boulevard~N4*Las Vegas*NV*89109~REF*EI*587654

321~HL*2*1*22*0~SBR*P*18*GRP01020102******CI~NM1*IL*1*Vaughn

*Steve*R***MI*MBRID12345~N3*236 Diamond ST~N4*Las Vegas*NV*8

9109~DMG*D8*19430501*M~NM1*PR*2*R&R Health Plan*****XY*PLANI

D12345~CLM*CLMNO12345*103.37***11:B:1*Y*A*Y*Y~HI*BK:03591~NM

1*82*1*Hendrix*Jim****XX*1122333341~PRV*PE*PXC*208D00000X~LX

*1~SV1*HC:90782*50*UN*1*11**1~DTP*472*D8*20040711~LX*2~SV1*H

C:J1550*53.37*UN*1*11**1~DTP*472*D8*20040711~AMT*T*3.37~LIN*

*N4*00026063512~CTP****10*ML~SE*31*0711~

3.1.10.2 Drug Example 2 - Home Infusion Therapy Pharmacy(Adjudicated with NDC in Loop 2410)

Example of services from a home infusion therapy pharmacy, which includes the billingfor the drugs delivered for administration in the home and where adjudication will befrom NDC number provided in Loop 2410.

SUBSCRIBER/PATIENT: Steve A. SmithADDRESS: 15210 Juliet Lane, Libertyville, IL 60048SEX: MDOB: 5/1/1943SUBSCRIBER IDENTIFICATION #: MBRID12345GROUP #: GRP01020102



SUBMITTER: Quality Billing Service CorporationETIN: 587654321CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801)726-8899

BILLING PROVIDER/SENDER: Professional Home IV, LLCADDRESS: 1500 Industrial Drive, Libertyville, IL 60048TIN: 10-1234567NATIONAL PROVIDER IDENTIFIER: 1234567893CONTACT PERSON AND PHONE NUMBER: Brenda Holly, (801)999-9999

PAY-TO PROVIDER: Professional Home IV, LLC

MAY 2006564



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CLM*CLMNO12345*103.37***11:B:1*Y*A*Y*Y**********08~

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ORDERING PROVIDER: Marcus WelbyNATIONAL PROVIDER IDENTIFIER: 1112223338

PATIENT ACCOUNT NUMBER: CLMNO12345

DIAGNOSIS: 465.9

CASE: The service is provided over a date span from 2/1/2004 to 2/7/2004 forprescriptions that the physician prescribed on 1/30/2004.

Provided is ceftriaxone, 2 gm IV, q24h over 7 days for gravity infusion through PICC lineto treat an acute upper respiratory infection. 20mls sterile water is the diluent forreconstitution of the ceftriaxone which is compounded into 100ml saline IV mini-bags.Also provided are all administration supplies and the pole necessary for the ceftriaxoneinfusion. Additionally, provided are all administration supplies, and flushing solutions(sodium chloride and heparin) prepackaged by the manufacturer in pre-filled syringes.

Drug service lines in this example begin after submission of a daily per diem charge of$200 per day of therapy, coded with HCPCS S9500 in the LX*1 service line. Drugs areprecisely coded with NDC numbers, and the HCPCS provided are S5000 and S5001for a generic drug and brand drug, respectively. The quantity and unit of measure sentfor each pair of NDC and HCPCS is the same, and the practice used for infusion therapyclaims is to provide a count of containers used, e.g. number of vials, number of bags,etc.

The health plan adjudicates the drug claim using the NDC in the 2410 LIN segment,quantity and unit of measure in the 2410 CTP segment, and charges in the 2400 SV1segment. For example, in the LX*2 service line, 7 units of ceftriaxone (NDC of00004-1965-01 which is for Rocephin®) is billed by the provider for total charge amountof $682.50. We note that as 00004-1965-01 Rocephin comes in a physical container of2gm vials, this means that the provider’s charge per vial of Rocephin is $97.50.

As S5000 and S5001 are used to map claim translation directly to the NDC coding foradjudication, payers should not reject occurrences of S5000 or S5001 because ofoverlapping dates.

Service lines LX*2, LX*3 and LX*4 contain the drugs that are elements of the compound.Service lines LX*5 and LX*6 are for non-compounded prescription drugs.

565MAY 2006



The primary purpose of this example is to demonstrate how drugs are billed along withservices when provided by a home infusion therapy pharmacy. Billing for the drugs isfound in segments #25-64 below.


HEADER


ST*837*0711*005010X222~

1


BHT*0019*00*0013*20040301*1200*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*Quality Billing Service

Corporation*****46*587654321~

3



4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*XYZ Receiver*****46*369852758~

5



HL*1**20*1~

6



NM1*85*2*Professional Home IV, LLC*****XX*1234567893~

7


N3*1500 Industrial Drive~

8


N4*Libertyville*IL*60048~

9


REF*EI*10-1234567~

10

MAY 2006566



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PER*IC*Brenda Holly*TE*8019999999~

11


HL - SUBSCRIBER

HL*2*1*22*0~

12


SBR*P*18*GRP01020102******CI~

13

2010BA SUBSCRIBER

NM1*IL*1*Smith*Steve*A***MI*MBRID01234~

14


N3*15210 Juliet Lane~

15

N4 SUBSCRIBER CITY


16


DMG*D8*19430501*M~

17


NM1 PAYER NAME


18

2300 CLAIM


CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y~

19


HI*BK:4659~

20

2400 SERVICE LINE


LX*1~

21


SV1*HC:S9500*1400.00*UN*7*12**1~

22

567MAY 2006



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CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y**********08~

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DTP*472*RD8*20040201-20040207~

23

2420E ORDERING PROVIDER NAME


NM1*DK*1*Welby*Marcus****XX*1112223338~

24

2400 SERVICE LINE

LX*2~

25


SV1*HC:S5001*682.50*UN*7*12**1~

26


DTP*472*RD8*20040201-20040207~

27

DTP DATE – PRESCRIPTION DATE

DTP*471*D8*20040130~

28



LIN**N4*00004196501~

29

CTP DRUG QUANTITY

CTP****7*UN~

30

REF PRESCRIPTION NUMBER

REF*XZ*2530001~

31




32

2400 SERVICE LINE COUNTER

LX*3~

33


SV1*HC:S5000*15.12*UN*14*12**1~

34


DTP*472*RD8*20040201-20040207~

35

MAY 2006568





DTP*471*D8*20040130~

36



LIN**N4*63323024910~

37

CTP DRUG QUANTITY

CTP****14*UN~

38


REF*XZ*2530001~

39




40


LX*4~

41


SV1*HC:S5000*67.69*UN*7*12**1~

42


DTP*472*RD8*20040201-20040207~

43


DTP*471*D8*20040130~

44



LIN**N4*00338004938~

45

CTP DRUG QUANTITY

CTP****7*UN~

46


REF*XZ*2530001~

47

569MAY 2006







48


LX*5~

49


SV1*HC:S5000*57.12*UN*14*12**1~

50


DTP*472*RD8*20040201-20040207~

51


DTP*471*D8*20040130~

52



LIN**N4*08290033010~

53

CTP DRUG QUANTITY

CTP****14*UN~

54


REF*XZ*2530002~

55




56


LX*6~

57


SV1*HC:S5000*10.50*UN*7*12**1~

58


DTP*472*RD8*20040201-20040207~

59


DTP*471*D8*20040130~

60

MAY 2006570






LIN**N4*08290038005~

61

CTP DRUG QUANTITY

CTP****7*UN~

62


REF*XZ*2530003~

63




64

TRAILER


SE*65*0711~

65


*41*2*Quality Billing Service Corporation*****46*587654321~P

ER*IC*Bud Holly*TE*8017268899~NM1*40*2*XYZ Receiver*****46*3

69852758~HL*1**20*1~NM1*85*2*Professional Home IV, LLC*****X

X*1234567893~N3*1500 Industrial Drive~N4*Libertyville*IL*600

48~REF*EI*10-1234567~PER*IC*Brenda Holly*TE*8019999999~HL*2*

1*22*0~SBR*P*18*GRP01020102******CI~NM1*IL*1*Smith*Steve*A**

*MI*MBRID01234~N3*15210 Juliet Lane~N4*Libertyville*IL*60048

~DMG*D8*19430501*M~NM1*PR*2*R&R Health Plan*****XY*PLANID123

45~CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y~HI*BK:4659~LX*1~S

V1*HC:S9500*1400.00*UN*7*12**1~DTP*472*RD8*20040201-20040207

~NM1*DK*1*Welby*Marcus****XX*1112223338~LX*2~SV1*HC:S5001*68

2.50*UN*7*12**1~DTP*472*RD8*20040201-20040207~DTP*471*D8*200

40130~LIN**N4*00004196501~CTP****7*UN~REF*XZ*2530001~NM1*DK*

1*Welby*Marcus****XX*1112223338~LX*3~SV1*HC:S5000*15.12*UN*1

4*12**1~DTP*472*RD8*20040201-20040207~DTP*471*D8*20040130~LI

N**N4*63323024910~CTP****14*UN~REF*XZ*2530001~NM1*DK*1*Welby

*Marcus****XX*1112223338~LX*4~SV1*HC:S5000*67.69*UN*7*12**1~

DTP*472*RD8*20040201-20040207~DTP*471*D8*20040130~LIN**N4*00

338004938~CTP****7*UN~REF*XZ*2530001~NM1*DK*1*Welby*Marcus**

571MAY 2006



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CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y**********08~

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**XX*1112223338~LX*5~SV1*HC:S5000*57.12*UN*14*12**1~DTP*472*

RD8*20040201-20040207~DTP*471*D8*20040130~LIN**N4*0829003301

0~CTP****14*UN~REF*XZ*2530002~NM1*DK*1*Welby*Marcus****XX*11

12223338~LX*6~SV1*HC:S5000*10.50*UN*7*12**1~DTP*472*RD8*2004

0201-20040207~DTP*471*D8*20040130~LIN**N4*08290038005~CTP***

*7*UN~REF*XZ*2530003~NM1*DK*1*Welby*Marcus****XX*1112223338~

SE*65*0711~

3.1.10.3 Drug Example 3 - Home Infusion Therapy Pharmacy(Adjudicated with HCPCS in Loop 2400 or NDC in Loop 2410)

Example of services from a home infusion therapy pharmacy, which includes the billingfor the drugs delivered for administration in the home and where adjudication may befrom either HCPCS code found in SV1 or NDC number provided in Loop 2410.

SUBSCRIBER/PATIENT: Steve A. SmithADDRESS: 15210 Juliet Lane, Libertyville, IL 60048SEX: MDOB: 5/1/1943SUBSCRIBER IDENTIFICATION #: MBRID12345GROUP #: GRP01020102



SUBMITTER: Quality Billing Service CorporationETIN: 587654321CONTACT PERSON AND PHONE NUMBER: Bud Holly, (801) 726-8899

BILLING PROVIDER/SENDER: Professional Home IV, LLCADDRESS: 1500 Industrial Drive, Libertyville, IL 60048TIN: 10-1234567NATIONAL PROVIDER IDENTIFIER: 1234567893CONTACT PERSON AND PHONE NUMBER: Brenda Holly, (801) 999-9999

PAY-TO PROVIDER: Professional Home IV, LLC

ORDERING PROVIDER: Marcus Welby

MAY 2006572



NATIONAL PROVIDER IDENTIFIER: 1112223338

PATIENT ACCOUNT NUMBER: CLM012345

DIAGNOSIS: 465.9

CASE: The service is provided over a date span from 2/1/2004 to 2/7/2004 forprescriptions that the physician prescribed on 1/30/2004.

Provided is ceftriaxone, 2 gm IV, q24h over 7 days for gravity infusion through PICC lineto treat an acute upper respiratory infection. 20mls sterile water is the diluent forreconstitution of the ceftriaxone which is compounded into 100ml saline IV mini-bags.Also provided are all administration supplies and the pole necessary for the ceftriaxoneinfusion. Additionally, provided are all administration supplies, and flushing solutions(sodium chloride and heparin) prepackaged by the manufacturer in pre-filled syringes.

Drug service lines in this example begin after submission of a daily per diem charge of$200 per day of therapy, coded with HCPCS S9500 in the LX*1 service line.

The drugs are coded with HCPCS j-codes and with NDC numbers.The quantity of unitsfor each pair of HCPCS j-code and NDC is not always the same. In HCPCS drug coding,the billed units of measure is described in the specific code description. For NDC codingin home infusion therapy claims, the billed units equal the containers used, e.g. numberof vials, number of bags, etc.:

• If the health plan is to adjudicate the drug claim using the provided HCPCS drug code(such as J0696 in LX*2), the plan obtains the charges, unit of measure and quantitybilled for the HCPCS drug code from the SV1 segment. While the provider has sentthe information of loop 2410, the plan may or may not use it for other purposes.

• However, if the health plan adjudicates the drug claim using loop 2410 information,this means the plan uses charges submitted in SV102 while quantity and unit ofmeasure are obtained from CTP04 and CTP05.While the unit of measure and quantityin SV103 and SV104 are to reflect the units appropriate for the HCPCS drug codedescription, the plan is not using them for adjudication.

• For example, in the LX*2 service line, 56 HCPCS units of ceftriaxone (HCPCS codeof J0696) is billed by the provider for total charge amount of $682.50. Equivalently,the provider is billing 7 units of ceftriaxone (NDC number 00004-1965-01 forRocephin®). As 00004-1965-01 Rocephin comes in a physical container of 2gm vials,this means that the provider’s charge per vial of Rocephin is $97.50. As the HCPCSdescription for J0696 is "injection, ceftriaxone sodium, per 250 mg", 8 units if J0696is equivalent to 1 unit of 00004-1965-01 ceftriaxone 2gm vial.

573MAY 2006



• As another example, in LX*3 we state much more briefly that billed are 14 vials ofsterile water, NDC 63323-0249-10. As each vial contains 10mls of sterile water, 28units of HCPCS J7051 are billed since the HCPCS description is "sterile saline orwater, up to 5 cc". Note: If there had existed a HCPCS drug code for 10mls of sterilewater, say code JXXXX for "sterile water, 10 cc", then the solution for LX*3 in thecomplete example that follows would have instead been:

LX*3~

SV1*HC:JXXXX*15.12*UN*14*12**1~

DTP*472*RD8*20040201-20040207~

DTP*471*D8*20040130~

LIN**N4*63323024910~

CTP****14*UN~

REF*XZ*2530001~


• For certain service lines, the HCPCS code submitted is J3490 "unclassified drugs"because there is a lack of clarity as to which of multiple available HCPCS j-codes areto be selected from. As therefore there are multiple occurrences of J3490, payersshould not reject occurrences of J3490 because of overlapping dates.

• When J3490 is used (see service lines LX*4, LX*5, and LX*6), specification of amountcharged, quantity billed, unit of measure, NDC number and prescription number issimilar to the solution provided in the previous example where HCPCS S5000 andS5001 were used in service lines LX*2 through LX*6.

• Service lines LX*2, LX*3 and LX*4 contain the prescription drugs that are elements ofthe compound. Service lines LX*5 and LX*6 are for non-compounded prescriptiondrugs.

Service lines LX*2, LX*3 and LX*4 contain the drugs that are elements of the compound.Service lines LX*5 and LX*6 are for non-compounded prescription drugs.

The primary purpose of this example is to demonstrate how drugs are billed along withservices when provided by a home infusion therapy pharmacy. Billing for the drugs isfound in segments #25-64 below.


HEADER


ST*837*0711*005010X222~

1

MAY 2006574



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005010X291



BHT*0019*00*0013*20040301*1200*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*Quality Billing Service

Corporation*****46*587654321~

3



4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*XYZ Receiver*****46*369852758~

5



HL*1**20*1~

6



NM1*85*2*Professional Home IV, LLC*****XX*1234567893~

7


N3*1500 Industrial Drive~

8



9


REF*EI*10-1234567~

10


PER*IC*Brenda Holly*TE*8019999999~

11


HL - SUBSCRIBER

HL*2*1*22*0~

12


SBR*P*18*GRP01020102******CI~

13

575MAY 2006




2010BA SUBSCRIBER

NM1*IL*1*Smith*Steve*A***MI*MBRID01234~

14


N3*15210 Juliet Lane~

15

N4 SUBSCRIBER CITY


16


DMG*D8*19430501*M~

17


NM1 PAYER NAME


18

2300 CLAIM


CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y~

19


HI*BK:4659~

20

2400 SERVICE LINE


LX*1~

21


SV1*HC:S9500*1400.00*UN*7*12**1~

22


DTP*472*RD8*20040201-20040207~

23




24

2400 SERVICE LINE

LX*2~

25

MAY 2006576



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CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y**********08~

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SV1*HC:J0696*682.50*UN*56*12**1~

26


DTP*472*RD8*20040201-20040207~

27


DTP*471*D8*20040130~

28



LIN**N4*00004196501~

29

CTP DRUG QUANTITY

CTP****7*UN~

30


REF*XZ*2530001~

31




32

2400 SERVICE LINE


LX*3~

33


SV1*HC:J7051*15.12*UN*28*12**1~

34


DTP*472*RD8*20040201-20040207~

35


DTP*471*D8*20040130~

36



LIN**N4*63323024910~

37

577MAY 2006




CTP DRUG QUANTITY

CTP****14*UN~

38


REF*XZ*2530001~

39




40

2400 SERVICE LINE


LX*4~

41


SV1*HC:J3490:::::Sod Chl 0.9% see NDC#*67.69*UN*7*12**1~

42


DTP*472*RD8*20040201-20040207~

43


DTP*471*D8*20040130~

44



LIN**N4*00338004938~

45

CTP DRUG QUANTITY

CTP****7*UN~

46


REF*XZ*2530001~

47




48

2400 SERVICE LINE


LX*5~

49

MAY 2006578





SV1*HC:J3490:::::Sod Chl 0.9% see NDC#*57.12*UN*14*12**1~

50


DTP*472*RD8*20040201-20040207~

51


DTP*471*D8*20040130~

52



LIN**N4*08290033010~

53

CTP DRUG QUANTITY

CTP****14*UN~

54


REF*XZ*2530002~

55




56

2400 SERVICE LINE


LX*6~

57


SV1*HC:J3490:::::Hep Lock see NDC#*10.50*UN*7*12**1~

58


DTP*472*RD8*20040201-20040207~

59


DTP*471*D8*20040130~

60



LIN**N4*08290038005~

61

579MAY 2006




CTP DRUG QUANTITY

CTP****7*UN~

62


REF*XZ*2530003~

63




64

TRAILER


SE*65*0711~

65


*41*2*Quality Billing Service Corporation*****46*587654321~P

ER*IC*Bud Holly*TE*8017268899~NM1*40*2*XYZ Receiver*****46*3

69852758~HL*1**20*1~NM1*85*2*Professional Home IV, LLC*****X

X*1234567893~N3*1500 Industrial Drive~N4*Libertyville*IL*600

48~REF*EI*10-1234567~PER*IC*Brenda Holly*TE*8019999999~HL*2*

1*22*0~SBR*P*18*GRP01020102******CI~NM1*IL*1*Smith*Steve*A**

*MI*MBRID01234~N3*15210 Juliet Lane~N4*Libertyville*IL*60048

~DMG*D8*19430501*M~NM1*PR*2*R&R Health Plan*****XY*PLANID123

45~CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y~HI*BK:4659~LX*1~S

V1*HC:S9500*1400.00*UN*7*12**1~DTP*472*RD8*20040201-20040207

~NM1*DK*1*Welby*Marcus****XX*1112223338~LX*2~SV1*HC:J0696*68

2.50*UN*56*12**1~DTP*472*RD8*20040201-20040207~DTP*471*D8*20

040130~LIN**N4*00004196501~CTP****7*UN~REF*XZ*2530001~NM1*DK

*1*Welby*Marcus****XX*1112223338~LX*3~SV1*HC:J7051*15.12*UN*

28*12**1~DTP*472*RD8*20040201-20040207~DTP*471*D8*20040130~L

IN**N4*63323024910~CTP****14*UN~REF*XZ*2530001~NM1*DK*1*Welb

y*Marcus****XX*1112223338~LX*4~SV1*HC:J3490:::::Sod Chl 0.9%

see NDC#*67.69*UN*7*12**1~DTP*472*RD8*20040201-20040207~DTP*

471*D8*20040130~LIN**N4*00338004938~CTP****7*UN~REF*XZ*25300

01~NM1*DK*1*Welby*Marcus****XX*1112223338~LX*5~SV1*HC:J3490:

::::Sod Chl 0.9% see NDC#*57.12*UN*14*12**1~DTP*472*RD8*2004

0201-20040207~DTP*471*D8*20040130~LIN**N4*08290033010~CTP***

MAY 2006580



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CLM*CLMNO12345*2232.93***12:B:1*Y*A*Y*Y**********08~

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005010X291

*14*UN~REF*XZ*2530002~NM1*DK*1*Welby*Marcus****XX*1112223338

~LX*6~SV1*HC:J3490:::::Hep Lock see NDC#*10.50*UN*7*12**1~DT

P*472*RD8*20040201-20040207~DTP*471*D8*20040130~LIN**N4*0829

0038005~CTP****7*UN~REF*XZ*2530003~NM1*DK*1*Welby*Marcus****

XX*1112223338~SE*65*0711~

3.1.11 Example 11 - PPO Repriced ClaimRepriced claim being transmitted from a Regional PPO (Preferred Provider Organization)to a commercial health insurance company. The patient is the same person as thesubscriber. In this situation, the provider has sent the claim to a clearinghouse, whichthen forwarded the claim to the repricer; the claim has been repriced and is now beingforwarded to the appropriate payer for payment.

SUBSCRIBER/PATIENT: Diamond D. Ring,ADDRESS: 123 Example Drive, Indianapolis, IN 462290000SEX: FDATE OF BIRTH: 12/29/1940EMPLOYER: COMPANY, INC.GROUP NUMBER: 123XYZMEMBER ID: 00124A089PATIENT ACCOUNT NUMBER: ABC123-RI


RECEIVER: Extra Healthy InsuranceRECEIVER ID: 112244

DESTINATION PAYER: Extra Healthy InsurancePAYER ID NUMBER: 12345

BILLING PROVIDER: HAPPY DOCTORS GROUP PRACTICEADDRESS: P O BOX 123, Fort Wayne, IN 462540000NATIONAL PROVIDER ID (NPI): 1234567890TAX IDENTIFICATION NUMBER (TIN): 555-51-2345

REFERRING PROVIDER: John DoeNATIONAL PROVIDER ID (NPI): 9988776655

RENDERING PROVIDER: Susan B. AnthonyNATIONAL PROVIDER ID (NPI): 1122334455

581MAY 2006



TOTAL CLAIM CHARGES: $28.75TOTAL CLAIM REPRICED AMOUNT: $26.75TOTAL CLAIM SAVINGS AMOUNT: $2.00

SERVICE LINE 1 REPRICING INFORMATION:TOTAL SERVICE LINE CHARGES: $25.00TOTAL REPRICED AMOUNT: $23.75SAVINGS AMOUNT: $1.25TIN FOR THE REPRICING ORGANIZATION: 908231234DATE OF SERVICE: 05/14/05

SERVICE LINE 2 REPRICING INFORMATION:TOTAL SERVICE LINE CHARGES: $3.75TOTAL REPRICED AMOUNT: $3SAVINGS AMOUNT: $.75TIN FOR THE REPRICING ORGANIZATION: 908231234DATE OF SERVICE: 05/14/05



ST*837*1002*005010X222~

1


BHT*0019*00*1002*20050620*09460000*CH~

2


NM1 SUBMITTER NAME


3



4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*EXTRA HEALTHY INSURANCE*****46*112244~

5



HL*1**20*1~

6

MAY 2006582



bclore

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005010X291

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NM1*85*2*HAPPY DOCTORS GROUP PRACTICE*****XX*1234567890~

7


N3*P O BOX 123~

8


N4*FORT WAYNE*IN*462540000~

9


REF*EI*555512345~

10


PER*IC*SUE BILLINGSWORTH*TE*8881231234~

11



HL*2*1*22*0~

12


SBR*P*18*123XYZ******CI~

13


NM1 SUBSCRIBER NAME

NM1*IL*1*RING*DIAMOND*D***MI*00124A089~

14


N3*123 EXAMPLE DRIVE~

15


N4*INDIANAPOLIS*IN*462290000~

16


DMG*D8*19401229*F~

17


NM1 PAYER NAME

NM1*PR*2*EXTRA HEALTHY INSURANCE*****PI*12345~

18

583MAY 2006






CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P~

19


REF*9A*0902352342~

20



REF*D9*061505501749388~

21


HI*BK>496*BF>25000~

22


HCP*03*26.75*2*908231234~

23

2310A REFERRING PROVIDER

NM1 REFERRING PROVIDER

NM1*DN*1*DOE*JOHN****XX*9988776655~

24


NM1 RENDERING PROVIDER

NM1*82*1*ANTHONY*SUSAN*B***XX*1122334455~

25



NM1*77*2*HAPPY DOCTORS GROUP~

26

N3 FACILITY ADDRESS

N3*123 FEEL GOOD ROAD~

27

N4 FACILITY LOCATION

N4*WASHINGTON*IN*475010000~

28

2400 SERVICE LINE


LX*1~

29


SV1*HC>E0570>RR*25*UN*1***1>2~

30

MAY 2006584



bclore

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CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P*********08~

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DTP*472*D8*20050514~

31


HCP*03*23.75*1.25*908231234~

32

2400 SERVICE LINE


LX*2~

33


SV1*HC>A7003>NU*3.75*UN*1***1~

34


DTP*472*D8*20050514~

35


HCP*03*3*.75*908231234~

36

TRAILER


SE*37*1002~

37


~NM1*41*2*REGIONAL PPO NETWORK*****46*123456789~PER*IC*SUBMI

TTER CONTACT INFO*TE*8001231234~NM1*40*2*EXTRA HEALTHY INSUR

ANCE*****46*112244~HL*1**20*1~NM1*85*2*HAPPY DOCTORS GROUP P

RACTICE*****XX*1234567890~N3*P O BOX 123~N4*FORT WAYNE*IN*46

2540000~REF*EI*555512345~PER*IC*SUE BILLINGSWORTH*TE*8881231

234~HL*2*1*22*0~SBR*P*18*123XYZ******CI~NM1*IL*1*RING*DIAMON

D*D***MI*00124A089~N3*123 EXAMPLE DRIVE~N4*INDIANAPOLIS*IN*4

62290000~DMG*D8*19401229*F~NM1*PR*2*EXTRA HEALTHY INSURANCE*

****PI*12345~CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P~REF*9A*0

902352342~REF*D9*061505501749388~HI*BK>496*BF>25000~HCP*03*2

6.75*2*908231234~NM1*DN*1*DOE*JOHN****XX*9988776655~NM1*82*1

*ANTHONY*SUSAN*B***XX*1122334455~NM1*77*2*HAPPY DOCTORS GROU

P~N3*123 FEEL GOOD ROAD~N4*WASHINGTON*IN*475010000~LX*1~SV1*

HC>E0570>RR*25*UN*1***1>2~DTP*472*D8*20050514~HCP*03*23.75*1

585MAY 2006



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35

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005010X291

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CLM*ABC123-RI*28.75***11>B>1*Y*A*Y*Y*P*********08~

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.25*908231234~LX*2~SV1*HC>A7003>NU*3.75*UN*1***1~DTP*472*D8*

20050514~HCP*03*3*.75*908231234~SE*37*1002~

3.1.12 Example 12 - Out of Network Repriced ClaimAn out of network claim is being transmitted from a Regional PPO (Preferred ProviderOrganization) to a commercial health insurance company. The patient is a child of thesubscriber. In this situation, the provider has sent the claim to a clearinghouse, whichthen forwarded the claim to the repricer; the claim has been determined to be out ofnetwork and is now being forwarded to the appropriate payer for payment.

SUBSCRIBER: Matthew R. SmithADDRESS: 5698 South Street, Billings, MO 919910000SEX: MDATE OF BIRTH: 10/15/1956EMPLOYER: Lumber Company.GROUP NUMBER: 232AAMEMBER ID: 57976235C

PATIENT: Tom E. SmithADDRESS: 5698 South Street, Billings, MO 919910000SEX: MDATE OF BIRTH: 08/07/1996PATIENT ACCOUNT NUMBER: TS234H3

OTHER INSURANCE: Secondary Insurance CompanyPAYER ID: 95645GROUP NUMBER: 56567OTHER INSURED MEMBER ID: 23424570


RECEIVER: Conservative InsuranceRECEIVER ID: 000110002

DESTINATION PAYER: Conservative InsurancePAYER ID NUMBER: 00123

BILLING PROVIDER: Emergency Physicians GroupADDRESS: 7423 Super Street, Billings, MO 919910000NATIONAL PROVIDER ID (NPI): 1122334455

MAY 2006586



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35

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Not applicable to predetermination of benefits request

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Delete rest of 3.1.12, leaving placeholder sentence.

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TAX IDENTIFICATION NUMBER (TIN): 111-00-2222

RENDERING PROVIDER: Jackie D. BlueNATIONAL PROVIDER ID (NPI): 1112223336

REPRICING INFORMATION:TOTAL CHARGES: $252.71TOTAL REPRICED AMOUNT: $0SAVINGS AMOUNT: $0TIN FOR THE REPRICING ORGANIZATION: 333001234DATE OF SERVICE: 05/06/05



ST*837*1024*005010X222~

1


BHT*0019*00*1024*20050711*1335*CH~

2


NM1 SUBMITTER NAME


3



4

1000B RECEIVER NAME

NM1 RECEIVER NAME

NM1*40*2*CONSERVATIVE INSURANCE*****46*000110002~

5



HL*1**20*1~

6



NM1*85*2*EMERGENCY PHYSICIANS GROUP*****XX*1122334455~

7


N3*7423 SUPER STREET~

8

587MAY 2006





N4*BILLINGS*MO*919910000~

9


REF*EI*111002222~

10



HL*2*1*22*1~

11


SBR*P**232AA******CI~

12


NM1 SUBSCRIBER NAME

NM1*IL*1*SMITH*MATTHEW*R***MI*57976235C~

13


N3*5698 SOUTH STREET~

14



15


DMG*D8*19561015*M~

16


NM1 PAYER NAME

NM1*PR*2*CONSERVATIVE INSURANCE*****PI*00123~

17

2000C - PATIENT HL LOOP

HL PATIENT HIERARCHICAL LEVEL

HL*3*2*23*0~

18


PAT*19~

19

2010CA PATIENT NAME

NM1 PATIENT NAME

NM1*QC*1*SMITH*TOM*E~

20

MAY 2006588






21

N4 PATIENT LOCATION


22


DMG*D8*19960807*M~

23



CLM*TS234H3*252.71***23>B>1*Y*A*Y*Y*P~

24


REF*9A*0902345406~

25



REF*D9*687534234346~

26


HI*BK>9951~

27

HCP HEALTH CARE PRICING - OUT OF NETWORK INFORMATION

HCP*00*0**333001234*********T1~

28


NM1 RENDERING PROVIDER

NM1*82*1*BLUE*JACKIE*D***XX*1112223336~

29



SBR*S*18*56567******CI~

30


DMG*D8*19960807*M~

31


OI***Y***Y~

32

589MAY 2006






NM1*IL*1*SMITH*TOM*E***MI*23424570~

33

N3 OTHER SUBSCRIBER ADDRESS


34

N4 OTHER SUBSCRIBER LOCATION


35



NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~

36

2400 SERVICE LINE


LX*1~

37


SV1*HC>99284*252.71*UN*1***1~

38


DTP*472*D8*20050506~

39

TRAILER


SE*40*1024~

40


*41*2*REGIONAL PPO NETWORK*****46*123456789~PER*IC*SUBMITTER

CONTACT INFO*TE*8001231234~NM1*40*2*CONSERVATIVE INSURANCE*

****46*000110002~HL*1**20*1~NM1*85*2*EMERGENCY PHYSICIANS GR

OUP*****XX*1122334455~N3*7423 SUPER STREET~N4*BILLINGS*MO*91

9910000~REF*EI*111002222~HL*2*1*22*1~SBR*P**232AA******CI~NM

1*IL*1*SMITH*MATTHEW*R***MI*57976235C~N3*5698 SOUTH STREET~N

4*BILLINGS*MO*919910000~DMG*D8*19561015*M~NM1*PR*2*CONSERVAT

IVE INSURANCE*****PI*00123~HL*3*2*23*0~PAT*19~NM1*QC*1*SMITH

*TOM*E~N3*5698 SOUTH STREET~N4*BILLINGS*MO*919910000~DMG*D8*

19960807*M~CLM*TS234H3*252.71***23>B>1*Y*A*Y*Y*P~REF*9A*0902

MAY 2006590



345406~REF*D9*687534234346~HI*BK>9951~HCP*00*0**333001234***

******T1~NM1*82*1*BLUE*JACKIE*D***XX*1112223336~SBR*S*18*565

67******CI~DMG*D8*19960807*M~OI***Y***Y~NM1*IL*1*SMITH*TOM*E

***MI*23424570~N3*5698 SOUTH STREET~N4*BILLINGS*MO*919910000

~NM1*PR*2*SECONDARY INSURANCE COMPANY*****PI*95645~LX*1~SV1*

HC>99284*252.71*UN*1***1~DTP*472*D8*20050506~SE*40*1024~

3.2 Property and CasualtyHealthcare Bill to Property & Casualty PayerThe requirements for submitting of Healthcare bills to Property & Casualty payers arepresented here.

837 Transaction SetHealthcare bills can be submitted to a Property & Casualty (P&C) payer. Becausecoverage is triggered by a specific event, certain information is critical to the billingprocess.

P&C bills must include both the bill information as well as the information related to theevent that caused the injury or illness. Information concerning the event is necessary toassociate a bill with the P&C claim.

P&C insurance is governed by State Insurance Regulations, Departments of Labor,Worker’s Compensation Boards, or other jurisdictionally defined entities, which oftenmandates compliance with Jurisdiction-specific procedures.

The Business Need: Provider to P&C Payer Bill Transmission

• The date of accident/occurrence/onset of symptoms (Date of Loss) is a critical pieceof information and must always be transmitted in the “Date - Accident” DTP segmentwithin Loop ID-2300 (Claim loop).

The Date of Loss is used to determine the eligibility of coverage.• The unique identification number, referred to in P&C as a claim number, must be

provided. The claim number is transmitted in the REF segment of Loop ID-2010BA ifthe patient is the subscriber or in the REF segment of Loop ID-2010CA if the patientis not the subscriber.

Without a date of loss on the bill and claim number, the bill will incomplete and maybe rejected.

591MAY 2006



3.2.1 Example 1 - Automobile AccidentBUSINESS SCENARIO: Automobile AccidentCLAIM TYPE: Automobile AccidentTYPE OF BILL: Emergency CarePRIMARY PAYER: Property & Casualty InsurerThe patient is a different person than the subscriber.The payer is a commercial Property& Casualty Insurance Company.

DATE OF ACCIDENT: 10/31/2005

SUBSCRIBER: Hal HowlingSUBSCRIBER ADDRESS: 327 Bronco Drive, Getaway, CA, 99999POLICY NUMBER: B999-777-91GINSURANCE COMPANY: Heisman Insurance CompanyCLAIM NUMBER: 32-3232-32

PATIENT: D.J. DimpsonPATIENT ADDRESS: 32 Buffalo Run, Rocking Horse, CA, 99666SEX: MDOB: 06/01/48CONTACT NUMBER: (815) 766-5902

DESTINATION PAYER/RECEIVER: Heisman Insurance CompanyPAYER ADDRESS: 1 Trophy Lane, NYAC, NY, 10032PAYER ID: 999888777

BILLING PROVIDER/SENDER: Associated Medical GroupPROVIDER SPECIALTY: General PracticeTIN: 579999999NATIONAL PROVIDER IDENTIFIER: 1253695747ADDRESS: 10 1/2 Shoemaker Street, Cobbler, CA, 99997TELEPHONE: 212-555-7987

PAY-TO-PROVIDER: Associated Medical Group

RENDERING PROVIDER: Bruno Moglie, MDNATIONAL PROVIDER IDENTIFIER: 2366552595

SERVICE FACILITY LOCATION: Associated Medical GroupPROVIDER SPECIALTY: General PracticeTIN: 579999999

MAY 2006592



NATIONAL PROVIDER IDENTIFIER: 1253695747ADDRESS: 101 East Pryor Street, Loma Linda, CA. 99622TELEPHONE: 342-555-7987PATIENT ACCOUNT NUMBER: 900-00-0032

CASE: The patient was a passenger in the subscriber’s automobile.The patient suffereda head and neck injury.

DIAGNOSIS: 854.0

SERVICES RENDERED: Office visit, Drain Abscess.DOS = 10/31/2005, POS = Office, TOS = Medical CareCHARGES: Office visit = $150.00, Suture wound = $35.00. Total charges = $185.00.


HEADER


ST*837*0021*005010X222~

1


BHT*0019*00*0125*20051111*1524*CH~

2

1000A SUBMITTER

NM1 SUBMITTER

NM1*41*2*ASSOCIATED MEDICAL GROUP*****46*1253695747~

3


PER*IC*JANICE HENDRIX*TE*2125557987~

4

1000B RECEIVER

NM1 RECEIVER NAME

NM1*40*2*HEISMAN INSURANCE COMPANY*****46*999888777~

5


HL BILLING PROVIDER

HL*1**20*1~

6



NM1*85*2*ASSOCIATED MEDICAL GROUP*****XX*1253695747~

7

593MAY 2006



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N3*10 1/2 SHOEMAKER STREET~

8

N4 BILLING PROVIDER CITY/STATE/ZIP CODE

N4*COBBLER*CA*99997~

9


REF*EI*579999999~

10


HL - SUBSCRIBER

HL*2*1*22*1~

11


SBR*P********AM~

12

2010BA SUBSCRIBER

NM1 SUBSCRIBER NAME

NM1*IL*1*HOWLING*HAL****MI*B99977791G~

13

2010BB SUBSCRIBER/PAYER

NM1 PAYER NAME

NM1*PR*2*HEISMAN INSURANCE COMPANY*****PI*999888777~

14


HL - PATIENT

HL*3*2*23*0~

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PAT*21~

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2010CA PATIENT NAME

NM1 PATIENT NAME

NM1*QC*1*DIMPSON*DJ~

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N3*32 BUFFALO RUN~

18


N4*ROCKING HORSE*CA*99666~

19

MAY 2006594





DMG*D8*19480601*M~

20

REF PROPERTY AND CASUALTY CLAIM NUMBER

REF*Y4*32323232~

21

PER PROPERTY AND CASUALTY PATIENT CONTACT INFORMATION

PER*IC*DJ DIMPSON*TE*8157665902~

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2300 CLAIM


CLM*900000032*185***11:B:1*Y*A*Y*Y**AA:::CA~

23

DTP DATE - ACCIDENT

DTP*439*D8*20051031~

24

DTP DATE - PROPERTY AND CASUALTY DATE OF FIRST CONTACT

DTP*444*D8*20051031~

25

HEALTH CARE DIAGNOSIS CODES

HI*BK:8540~

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NM1*82*1*MOGLIE*BRUNO****XX*2366552595~

27

PRV RENDERING PROVIDER SPECIALTY INFORMATION

PRV*PE*PXC*208D00000X~

28

2310C SERVICE FACILITY LOCATION


NM1*77*2*ASSOCIATED MEDICAL GROUP*****XX*1235767887~

29

N3 SERVICE FACILITY LOCATION ADDRESS

N3*101 EAST PRYOR STREET~

30

N4 SERVICE FACILITY LOCATION CITY/STATE/ZIP

N4*LOMA LINDA*CA*99622~

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PER PROPERTY AND CASUALTY SERVICE FACILITY CONTACT INFORMATION

PER*IC*KAREN SPARKLE*TE*3425557987~

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595MAY 2006



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2400 SERVICE LINE


LX*1~

33


SV1*HC:99201*150*UN*1***1**Y~

34


DTP*472*D8*20051031~

35

2400 SERVICE LINE


LX*2~

36


SV1*HC:26010*35*UN*1***1**Y~

37


DTP*472*D8*20051031~

38

TRAILER


SE*39*0021~

39


*41*2*ASSOCIATED MEDICAL GROUP*****46*1253695747~PER*IC*JANI

CE HENDRIX*TE*2125557987~NM1*40*2*HEISMAN INSURANCE COMPANY*

****46*999888777~HL*1**20*1~NM1*85*2*ASSOCIATED MEDICAL GROU

P*****XX*1253695747~N3*10 1/2 SHOEMAKER STREET~N4*COBBLER*CA

*99997~REF*EI*579999999~HL*2*1*22*1~SBR*P********AM~NM1*IL*1

*HOWLING*HAL****MI*B99977791G~NM1*PR*2*HEISMAN INSURANCE COM

PANY*****PI*999888777~HL*3*2*23*0~PAT*21~NM1*QC*1*DIMPSON*DJ

~N3*32 BUFFALO RUN~N4*ROCKING HORSE*CA*99666~DMG*D8*19480601

*M~REF*Y4*32323232~PER*IC*DJ DIMPSON*TE*8157665902~CLM*90000

0032*185***11:B:1*Y*A*Y*Y**AA:::CA~DTP*439*D8*20051031~DTP*4

44*D8*20051031~HI*BK:8540~NM1*82*1*MOGLIE*BRUNO****XX*236655

2595~PRV*PE*PXC*208D00000X~NM1*77*2*ASSOCIATED MEDICAL GROUP

*****XX*1235767887~N3*101 EAST PRYOR STREET~N4*LOMA LINDA*CA

MAY 2006596



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005010X291

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CLM*900000032*185***11:B:1*Y*A*Y*Y**AA:::CA********08~

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*99622~PER*IC*KAREN SPARKLE*TE*3425557987~LX*1~SV1*HC:99201*

150*UN*1***1**Y~DTP*472*D8*20051031~LX*2~SV1*HC:26010*35*UN*

1***1**Y~DTP*472*D8*20051031~SE*39*0021~

597MAY 2006



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